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"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.
B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.
C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.
D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.
Correct Answer is B
Explanation
Choice A rationale:
Changing the inner cannula on a tracheostomy is within the legal scope of practice for registered nurses. Nurses are trained to perform tracheostomy care, including changing the inner cannula. This procedure is within the nursing scope of practice and does not require a physician's intervention.
Choice B rationale:
Inserting a tunneled central venous catheter (such as a Hickman line) is a specialized procedure that generally falls under the scope of practice for advanced practice nurses (such as nurse practitioners or clinical nurse specialists) or physicians. RNs typically do not have the required training or authority to perform this invasive procedure.
Choice C rationale:
Irrigation of an external ear canal is within the legal scope of practice for registered nurses. Ear irrigation is a common nursing procedure used to remove impacted cerumen (earwax) and foreign bodies from the ear canal. Nurses are trained to perform this procedure safely and effectively.
Choice D rationale:
Administering blood products, including platelet transfusions, is within the legal scope of practice for an RN. RNs are responsible for preparing, verifying, and administering blood products according to institutional policies and procedures. This includes monitoring the patient during and after the transfusion for any adverse reactions.
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