11. A client is receiving 125 ml/hr of continuous IV fluid therapy. The nurse examines the venipuncture site and finds it red and swollen. Which of the following interventions would the nurse perform first?A. slow the infusion to 10 ml/hr
B. discontinue the infusion
C. place cold towels on the site
D. call the physician
13. After surgery, a client is being discharged with acetaminophen and codeine tablets, 30 mg. for pain. During the client's discharge preparations, which of the following instructions should the nurse include?
A. avoid driving a car while taking the medication
B. decrease your fluid intake to two glasses a day
C. take the medication on an empty stomach
D. watch for fine motor tremors
14. Which action is essential when the nurse provides a continuous enteral feeding?
A. elevate the head of the bed
B. position the client on his left side
C. warm the formula before administering it
D. attach the feeding bag to the current tubing
15. Which of these foods should the nurse include to promote healing?
A. fresh orange slices
B. ground-beef patties
C. steamed broccoli
D. ice cream
16. A nurse is instructing an Indian-American client on collecting sputum specimen. The nurse observes that the client continuously stares at the floor during instructional sessions. The nurse interprets this behavior as:
A. rude
B. lack of interest
C. embarrassment
D. indicative that the client is paying close attention
17. A client in the telemetry unit refuses to take a prescribed medication. The nurse threatens the clients and tells the client that if the medication is not taken orally, then restraints will be applied and the medication will be given by injection. This statement by the nurse constitutes which legal case?
A. invasion of privacy
B. negligence
C. assault
D. battery
18. The nurse would assign highest priority to which of the following clients?
A. a client with scheduled for transesophageal echocardiography at 9:00 A.M.
B. a client with chest pain who states that he just had bowel movement in the toilet
C. a client newly diagnosed with diabetes mellitus scheduled for discharge to home
D. a client complaining of muscle aches, headache, and malaise
19. A client's serum sodium level is 152 mEq/L. Which of the following food items does the nurse instruct the client to avoid?
A. low-fat yogurt
B. broccoli
C. processed oat-cereals
D. brussel sprout
20. A client had undergone appendectomy. He is on clear liquid diet initially. Which of the following items may be allowed to be taken by the client? Select all that apply:
A. broth
B. gelatin
C. pudding
D. pureed vegetables
E. coffee
F. vegetable juice
ANSWERS AND RATIONALE
11) B
- The signs and symptoms in the situation indicate extravasation; the IV device should be discontinued immediately and warm, not cold towels applied to the site
13) A
- Codeine can cause drowsiness. The client should avoid driving when taking this medication to prevent accident. The medication should be taken with food to prevent nausea and vomiting. Codeine can also cause dizziness but not fine motor tremors. Fluid restriction may cause constipation.
14) A
- elevating the head of the bed during an enteral feeding prevents aspiration and facilitates flow of the formula into the intestines. The client may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to minimize GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.
15) B
- proteins, like meat promote repair of tissue breakdown from the pressure ulcers. Meat is more complete source of protein as compared with ice cream. Oranges and broccoli supply vitamin C but not protein.
16) D
- in this culture, eye contact is considered as a sign of disrespect. This behavior indicates that the client is paying close attention to the speaker
17) C
- Rationale: An assault occurs when a person puts another person in fear of a harmful of offensive contact.
Battery is actual contact with one's body. Negligence involves actions below standards of care. Invasion of privacy occurs with unreasonable intrusion into the individual's private affairs.
18. B
- the client with chest pain after having a bowel movement may be experiencing myocardial infarction and therefore, is given highest priority . ABC is a priority.
19) C
- the client is having hpernatremia. The normal serum sodium level is 135 to 145 mEq/L. The client should avoid foods high in sodium like processed foods. Low-fat yogurt, broccoli and brussel sprout are good food sources of phosphorus.
20) A, B, C, E
- these are foods are relatively transparent to light and are clear and liquid at room and body temperature. Other foods that may be included in clear liquid diet are water, bouillion, carbonated beverages, hard candy, lemonade, popsicles and tea.
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B. discontinue the infusion
C. place cold towels on the site
D. call the physician
13. After surgery, a client is being discharged with acetaminophen and codeine tablets, 30 mg. for pain. During the client's discharge preparations, which of the following instructions should the nurse include?
A. avoid driving a car while taking the medication
B. decrease your fluid intake to two glasses a day
C. take the medication on an empty stomach
D. watch for fine motor tremors
14. Which action is essential when the nurse provides a continuous enteral feeding?
A. elevate the head of the bed
B. position the client on his left side
C. warm the formula before administering it
D. attach the feeding bag to the current tubing
15. Which of these foods should the nurse include to promote healing?
A. fresh orange slices
B. ground-beef patties
C. steamed broccoli
D. ice cream
16. A nurse is instructing an Indian-American client on collecting sputum specimen. The nurse observes that the client continuously stares at the floor during instructional sessions. The nurse interprets this behavior as:
A. rude
B. lack of interest
C. embarrassment
D. indicative that the client is paying close attention
17. A client in the telemetry unit refuses to take a prescribed medication. The nurse threatens the clients and tells the client that if the medication is not taken orally, then restraints will be applied and the medication will be given by injection. This statement by the nurse constitutes which legal case?
A. invasion of privacy
B. negligence
C. assault
D. battery
18. The nurse would assign highest priority to which of the following clients?
A. a client with scheduled for transesophageal echocardiography at 9:00 A.M.
B. a client with chest pain who states that he just had bowel movement in the toilet
C. a client newly diagnosed with diabetes mellitus scheduled for discharge to home
D. a client complaining of muscle aches, headache, and malaise
19. A client's serum sodium level is 152 mEq/L. Which of the following food items does the nurse instruct the client to avoid?
A. low-fat yogurt
B. broccoli
C. processed oat-cereals
D. brussel sprout
20. A client had undergone appendectomy. He is on clear liquid diet initially. Which of the following items may be allowed to be taken by the client? Select all that apply:
A. broth
B. gelatin
C. pudding
D. pureed vegetables
E. coffee
F. vegetable juice
ANSWERS AND RATIONALE
11) B
- The signs and symptoms in the situation indicate extravasation; the IV device should be discontinued immediately and warm, not cold towels applied to the site
13) A
- Codeine can cause drowsiness. The client should avoid driving when taking this medication to prevent accident. The medication should be taken with food to prevent nausea and vomiting. Codeine can also cause dizziness but not fine motor tremors. Fluid restriction may cause constipation.
14) A
- elevating the head of the bed during an enteral feeding prevents aspiration and facilitates flow of the formula into the intestines. The client may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to minimize GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.
15) B
- proteins, like meat promote repair of tissue breakdown from the pressure ulcers. Meat is more complete source of protein as compared with ice cream. Oranges and broccoli supply vitamin C but not protein.
16) D
- in this culture, eye contact is considered as a sign of disrespect. This behavior indicates that the client is paying close attention to the speaker
17) C
- Rationale: An assault occurs when a person puts another person in fear of a harmful of offensive contact.
Battery is actual contact with one's body. Negligence involves actions below standards of care. Invasion of privacy occurs with unreasonable intrusion into the individual's private affairs.
18. B
- the client with chest pain after having a bowel movement may be experiencing myocardial infarction and therefore, is given highest priority . ABC is a priority.
19) C
- the client is having hpernatremia. The normal serum sodium level is 135 to 145 mEq/L. The client should avoid foods high in sodium like processed foods. Low-fat yogurt, broccoli and brussel sprout are good food sources of phosphorus.
20) A, B, C, E
- these are foods are relatively transparent to light and are clear and liquid at room and body temperature. Other foods that may be included in clear liquid diet are water, bouillion, carbonated beverages, hard candy, lemonade, popsicles and tea.
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