The nurse is teaching a client who will be collecting a stool sample for a hemoccult test. The nurse determines that teaching has been effective when the client states:

"I shouldn't take my vitamin D pill before the stool sample is collected."

"I should take a laxative to help me pass my stool."

"I must avoid drinking milk before collecting the stool sample."

"Any meat that I eat before I collect my stool sample must be fully cooked."

Answer and Explanation

The Correct Answer is D

A. "I shouldn't take my vitamin D pill before the stool sample is collected." Vitamin D supplements are unlikely to interfere with the hemoccult test, as they typically do not contain substances that affect the detection of occult blood in the stool. Therefore, this statement does not demonstrate an understanding of factors relevant to the stool sample collection for the hemoccult test.

B. "I should take a laxative to help me pass my stool." Taking a laxative before collecting the stool sample is not recommended, as it can alter the consistency and composition of the stool, potentially affecting the accuracy of the hemoccult test. Laxatives may also cause diarrhea, leading to difficulty in collecting a sufficient sample. Therefore, this statement is incorrect and does not reflect effective teaching regarding stool sample collection for the hemoccult test.

C. "I must avoid drinking milk before collecting the stool sample." While certain dietary restrictions may be necessary for specific diagnostic tests, drinking milk is not typically prohibited before collecting a stool sample for a hemoccult test. Milk consumption is unlikely to interfere with the test results or the detection of occult blood in the stool. Therefore, this statement is not relevant to the hemoccult test and does not demonstrate understanding of appropriate preparation for the test.

D. "Any meat that I eat before I collect my stool sample must be fully cooked." This statement reflects an understanding of food safety and hygiene practices relevant to stool sample collection for the hemoccult test. Fully cooked meat reduces the risk of bacterial contamination in the stool sample, which could interfere with the accuracy of the test results. Therefore, this statement demonstrates effective teaching regarding the importance of food preparation in ensuring accurate test results for the hemoccult test.

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Correct Answer is B

Explanation

A. Asking the client to bear down as if urinating: This action is not appropriate in this situation because the lack of urine output may not necessarily be due to the client's inability to void. Checking for other potential issues, such as kinks in the tubing, is more appropriate as a first step.

B. Check for kinks in the tubing: This is the most appropriate first action. Kinks in the tubing can obstruct urine flow from the bladder to the drainage bag, leading to decreased or no urine output. By checking for kinks, the nurse can quickly identify and correct any obstructions, potentially resolving the issue without further intervention.

C. Increasing fluid intake: While maintaining adequate hydration is important for overall urinary function, it is not the most immediate action needed when there is no urine output in the catheter bag. Addressing potential mechanical issues, such as kinks in the tubing, takes precedence.

D. Inserting a new indwelling urinary catheter: Inserting a new catheter should not be the first action taken without investigating other potential causes for the lack of urine output. It is important to troubleshoot and address possible issues with the current catheter and drainage system before considering catheter replacement.

A. Administering diuretics as ordered B. Providing good skin and mouth care C. Monitoring intake and output D. Obtaining daily weights

Correct Answer is ["B","C","D"]

Explanation

A. Administering diuretics as ordered: This option is not appropriate for dehydration management. Diuretics are medications that increase urine output and are typically used to treat fluid overload rather than dehydration. Administering diuretics to a dehydrated client could exacerbate fluid loss and worsen the condition.

B. Providing good skin and mouth care: This is a suitable intervention for managing dehydration. Dehydration can lead to dry skin and mucous membranes. Providing good skin care, including moisturizing, can help prevent skin breakdown. Additionally, ensuring adequate oral hygiene and providing moist mouth swabs can alleviate discomfort associated with dry mouth.

C. Monitoring intake and output: This is an essential nursing intervention for managing dehydration. Monitoring the client's fluid intake and output allows the nurse to assess the balance between fluid intake and loss. Decreased urine output is a common sign of dehydration, while monitoring intake helps ensure the client is receiving adequate fluids.

D. Obtaining daily weights: This is an appropriate nursing intervention for managing dehydration. Daily weights can help assess changes in fluid balance. A sudden increase in weight may indicate fluid retention, while a decrease may indicate ongoing fluid loss, both of which are important to monitor in dehydration.

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The nurse is teaching a client who will be collecting a stool sample for a hemoccult test. The nurse determines that teaching has been effective when the client states:

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Naxlex Comprehensive Predictor Exams

The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?

Correct Answer is B

Explanation

The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

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