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A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Which of the following statements should the nurse include in the client's teaching?

Select all that apply.

Try using an abdominal support belt

Take hot showers to help relieve itching"

"Wear loose-fitting clothing"

"Eat two large meals a day."

You should avoid fried foods"

Answer and Explanation

Correct Answer : C,D,G

Choice A reason:

"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.

Choice B reason:

"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.

Choice C reason:

"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.

Choice D reason:

"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.

Choice E reason:

"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.

Choice F reason:

"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.

Choice G reason:

"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.

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Correct Answer is C

Explanation

A. Incorrect. Securing the tracheostomy tube with ties is important, but this is a task that should be performed by healthcare professionals initially. It is not typically part of discharge teaching.
B. Incorrect. Changing the tracheostomy dressing using clean technique is also an essential skill but may not be suitable for discharge teaching. The partner should be educated on monitoring the stoma site and recognizing signs of infection or complications.
C. Correct. Teaching the partner how to operate the portable suction machine is crucial for maintaining a patent airway. Suctioning is often necessary to clear mucus and secretions from the tracheostomy tube, especially when the client is at home.
D. Incorrect. Changing a tracheostomy tube, particularly a nondisposable one, is a procedure that should be performed by healthcare professionals due to the risk of complications and the need for sterile technique. It is not typically part of discharge teaching to non-medical caregivers.

A. A client who is scheduled for a procedure in 1 hr B. A client who received a pain medication 30 min ago for postoperative pain C. A client who has 100 mL of fluid remaining in his IV bag D. A client who was just given a glass of orange juice for a low blood glucose level

Correct Answer is D

Explanation

A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia

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A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.Which of the following actions should the nurse include in the plan?

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?

A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?

A nurse is providing discharge teaching to a client who has GERD.Which of the following information should the nurse include?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)