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A nurse is providing teaching about dietary options for a clinet who has cholelithiasis. Which of the following statements should the nurse include in teaching? "Cauliflower is a good dietary choice. ... " "Increase the amount of egg yolks in your diet." "Select desserts such as angel-food cake." "Eat choice or prime cuts of meat." - ✔✔Angel Food: Clients who have acute cholelithiasis will be prescribed a low-fat diet. Desserts such as sherbet, gelatin, and angel food cake are dessert choices that are low in fat. Other options are high in fat and cauliflower is gas-forming A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? A pearly, waxy nodule An irregular border on a variegated-colored lesion A firm, nodular, crusty, or ulcerated lesion A weeping vesicle - ✔✔A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a pearly or waxy appearance, resulting from overexposure to the sun, especially on the face, head, and neck. What would a client have if they had an irregular border on a variegated-colored lesion? - ✔✔Melanoma What would a client have if they had a firm, nodular, crusty, or ulcerated lesion? - ✔✔squamous cell carcinoma A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following should the nurse identify as a manifestation of type 1 diabetes? Hypernatremia Decreased serum osmolality Ketones in the urine Hypoglycemia - ✔✔Ketones in urine: Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels. A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective? The client's daily peak expiratory flow (PEF) measures 85% above personal best. The client's ABGs shows a pH level of 7.32. The client's forced expiratory volume is decreased after treatment with medication. The client's wheezing is limited to expiratory. - ✔✔The client's daily peak expiratory flow (PEF) measures 85% above personal best; A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left sided heart failure? Dependent edema Jugular distention Weight gain Frothy sputum - ✔✔Frothy Sputum; The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching? "If my heart starts racing, my provider might need to adjust my dosage." "I will keep a journal of my daily food intake to show the provider." "Once my weight is back to normal, I can gradually reduce and then stop the medication." "I'm not forgetful, so I do not need a pill reminder system." - ✔✔"If my heart starts racing, my provider might need to adjust my dosage."; Levothyroxine increases metabolism, which can increase oxygen consumption and heart rate. If the client's heart is racing, the dosage might be too high, causing thyrotoxicosis with manifestations of tachycardia, insomnia, tremors and nervousness, hyperthermia, heat intolerance, and sweating. The provider should retest the client's thyroid hormone levels and adjust the dosage accordingly. A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching? Give each screw a quarter turn daily using the wrench provided. Apply powder liberally under the chest portion of the halo fixator device. Avoid the use of straws when drinking liquids. Place a small pillow under the head while lying supine. - ✔✔Place a small pillow under the head while lying supine.; The halo fixator device is worn for a period of 8 to 12 weeks and immobilizes the cervical spine, preventing flexion and hyperextension of the neck. The use of a small pillow under the head provides support to the head and neck, preventing additional discomfort and pressure from the device. A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include? Remove clutter from rooms and hallways. Place a monthly calendar in the client's room. Use confrontation to manage the client's behavior. Review the daily schedule with the client every morning. - ✔✔Remove clutter from rooms and hallways A nurse is assessing a client who has a CVC with IV fluids infusing. The client suddenly develops SOB, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first? Close the pinch clamp on the CVC. Obtain a prescription for stat ABGs. Place the client in left Trendelenburg position. Check the tubing for placement of a locking adaptor. - ✔✔Close and pinch clamp on the CVC; The greatest risk to this client is air embolism resulting from accidental disconnection of the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the pinch clamp to prevent any further air from entering the system. When an air embolism occurs, air enters through the central vein into the right ventricle and lodges by the pulmonary valve, decreasing the amount of blood that is able to enter into the ventricle and the pulmonary arteries. Normal limits for urine specific gravity - ✔✔1.005-1.030 A nurse is caring for a client who is receiving Vancomycin intermittent IV bolus therapy for MRSA. Which of the following indiction to the nurse that the client is experiencing an adverse effect of the medication? The client's blood pressure is elevated. The client is becoming flushed. The client reports blurred vision. The client is experiencing polyuria. - ✔✔Flushed; Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome. Red man syndrome results from infusing vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. What are the 2 most reliable way for verifying placement of the ET tube? - ✔✔Xray and check end-tidal carbon dioxide levels What dressing type would cover skeletal traction pins? - ✔✔sterile, absorbent, nonadherent dressing What wounds is a hydrocolloid dressing used for? - ✔✔necrotic or granulating [Show More]

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