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 C
Explanation
A. Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.
B. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Encouraging a client to cough during suctioning is generally acceptable because coughing helps expel secretions from the airway.However, the nurse should ensure that the client does not cough too forcefully, as this could lead to trauma or discomfort.
D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Correct Answer is D
Explanation
A. Incorrect. Mild swelling under the sutures is a common finding after surgery and may not necessarily require reporting unless it worsens or is associated with other concerning symptoms.
B. Incorrect. Pink-tinged coloration can be a normal part of the healing process, as long as there is no excessive redness, warmth, or signs of infection.
C. Incorrect. Crusting of exudate on the incisional line can occur during the healing process and may not necessarily indicate a problem unless it's accompanied by signs of infection.
D. Correct. Partial separation of the upper part of the incisional line can indicate wound dehiscence, a potential complication that requires immediate attention to prevent infection and further complications.
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