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NEW QUESTION 37
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

• A. Oatmeal, whole-wheat toast, and milk
• B. Corn beef and cabbage and boiled potatoes
• C. Peanut butter and jelly sandwich and milk
• D. Tuna on whole-wheat bread and iced tea

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.

NEW QUESTION 38
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

• A. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
• B. Give fluids if the client requests them.
• C. Measure vital signs at least every 4 hours.
• D. Release restraints every 2 hours for client to exercise.

Answer: D

Explanation:
Explanation/Reference:
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

NEW QUESTION 39
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

• A. Fruit juices
• B. Diluted carbonated drinks
• C. Regular formulas mixed with electrolyte solutions
• D. Soy-based, lactose-free formula

Answer: D

Explanation:
Explanation/Reference:
Explanation:
(A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea.
(B) Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain lactose, which can increase diarrhea.

NEW QUESTION 40
A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?

• A. "HIV is a virus transmitted by sexual contact."
• B. "HIV is a virus that is easily transmitted by casual contact."
• C. "Condoms reduce the transmission of HIV."
• D. "HIV can be transmitted to an unborn infant."

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.

NEW QUESTION 41
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?

• A. Turn the client to her left side.
• B. Notify physician of nonreassuring FHR pattern.
• C. Evaluate to see if the monitor strip is reassuring.
• D. Start IV for fetal distress and administer O2 at 6-8 liters by mask.

Answer: C

Explanation:
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician. (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.

NEW QUESTION 42
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