Question

A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following statements indicates the client understands the best choice for a high-fiber

Answer 1

Correct Answers:

"My breakfast choice is 1/2 cup of bran cereal."

Rationale :

▶Bran cereal is one of the highest natural sources of dietary fiber, making it a superior choice for managing constipation. ▶It contains insoluble fiber that promotes bowel movement by increasing stool bulk and decreasing intestinal transit time. ▶While almonds and apples provide some fiber, bran cereal offers a more concentrated source. ▶Sweet potatoes also contain fiber, but not as much per serving as bran cereal.

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Answer 2

Correct Answers:

Scrambled eggs

Rationale :

✅A full liquid diet consists of liquids or foods that turn to liquid at room temperature and can be poured. ✅Scrambled eggs are not part of a full liquid diet because they do not liquefy and require chewing. ✅In contrast, apple juice, cream of rice cereal (if thinned), and vanilla yogurt are appropriate as they meet the consistency requirement.

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Answer 3

Correct Answers:

Eat raw vegetables.

Rationale :

🔹Raw vegetables are high in dietary fiber, which adds bulk to the stool and promotes peristalsis, helping alleviate constipation. 🔹This is especially important for older adults who often have decreased gastrointestinal motility. 🔹Limiting fluids or reducing activity would worsen constipation, and bearing down increases the risk of complications such as hemorrhoids or vasovagal syncope.

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Answer 4

Correct Answers:

Use a filter needle to draw up the medication-

Rationale :

✅When withdrawing medication from a glass ampule, a filter needle must be used to prevent the administration of any glass particles that may result from snapping the ampule open. ✅Shaking the ampule is not appropriate as it can increase air bubbles, and snapping should be done away from the hands to avoid injury. ✅Sterile gloves are not required for this step.

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Answer 5

Correct Answers:

Request a potassium replacement

Rationale :

🔹A potassium level of 3.0 mEq/L indicates hypokalemia, which can lead to muscle weakness, cardiac arrhythmias, and potentially life-threatening complications. 🔹The priority is to correct the potassium imbalance, typically through supplementation. 🔹The other labs are within normal limits, and there's no indication to stop TPN or administer glucagon.

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Answer 6

Correct Answers:

Add fluid and fiber to the diet.

Rationale :

✅In older adults, constipation is commonly related to decreased physical activity, reduced fluid intake, and insufficient dietary fiber. ✅Adding fluids and high-fiber foods such as fruits, vegetables, and whole grains enhances stool bulk and softens the stool, thereby promoting natural bowel elimination. ✅This non-pharmacologic approach is the first-line intervention before initiating medications. ✅ Increasing mobility and stool softeners may be considered if dietary measures are insufficient, but fiber and hydration are foundational.

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Answer 7

Correct Answers:

Place all clients who have manifestations on contact precautions-

Rationale :

🔹Clostridium difficile (C. difficile) is transmitted through contact with contaminated surfaces or hands and requires strict infection control. 🔹 The nurse must immediately implement contact precautions (gown and gloves) for clients with symptoms such as watery diarrhea to prevent nosocomial transmission. 🔹Soap and water—not alcohol-based rubs—should be used for hand hygiene due to spore resistance. 🔹Isolation protocols are a priority while awaiting lab confirmation.

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Answer 8

Correct Answers:

Cardiac dysrhythmias

Rationale :

⚫A potassium level of 3.0 mEq/L indicates hypokalemia, which alters myocardial cell excitability and conduction. ⚫This disturbance can precipitate serious cardiac dysrhythmias such as ventricular tachycardia or premature ventricular contractions. ⚫ Monitoring for arrhythmias is essential, especially in clients on loop diuretics, which cause potassium loss. ⚫Early recognition and potassium replacement are critical to prevent complications.

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Answer 9

Correct Answers:

The spacer increases the amount of medication delivered to the lungs.

Rationale :

🔹Using a spacer with a metered-dose inhaler (MDI) enhances drug delivery to the lower respiratory tract by suspending medication particles in a chamber, allowing for deeper inhalation. 🔹This minimizes oropharyngeal deposition and improves medication efficacy in the lungs, which is critical in asthma management. 🔹It also reduces coordination issues and side effects like oral thrush associated with corticosteroids.

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Answer 10

Correct Answers:

Sim's

Rationale :

🔹The Sim’s position—left lateral with the right knee flexed—aligns the rectum for optimal suppository insertion by following the natural anatomical curve. 🔹It provides comfort, privacy, and access while minimizing the risk of mucosal injury. 🔹This position also allows the suppository to remain in place and dissolve properly, facilitating effective absorption.

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QLexNursing

1 : A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following statements indicates the client understands the best choice for a high-fiber

2 : A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

3 : A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should the nurse make?

4 : A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

5 : A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dl, chloride 100 mEq/L. sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

6 : A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

7 : A nurse working on a medical-surgical unit suspects that several clients have Clostridium difficile (C. difficile) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

8 : A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

9 : A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?

10 : A nurse is preparing to administer a rectal suppository to a client. The nurse should instruct the client to lie in which of the following positions while in bed?