Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse
include in the plan?
A. Sliced ham with green salad
Choice A reason: This is incorrect. Sliced ham with green salad is not a good menu selection for a client who has diverticulitis. Ham is high in fat and salt, which can irritate the digestive tract and worsen inflammation. Green salad contains raw vegetables, which are high in fiber and can increase bowel movements and pressure on the diverticula. Diverticula are small pouches that form in the wall of the colon and can become inflamed or infected.
B. Grilled chicken breast with white rice
Choice B reason: This is the correct answer. Grilled chicken breast with white rice is a good menu selection for a client who has diverticulitis. Chicken breast is low in fat and high in protein, which can promote healing and prevent malnutrition. White rice is low in fiber and easy to digest, which can reduce bowel movements and pressure on the diverticula.
C. Pork tenderloin with green peas
Choice C reason: This is incorrect. Pork tenderloin with green peas is not a good menu selection for a client who has diverticulitis. Pork tenderloin is high in fat, which can irritate the digestive tract and worsen inflammation. Green peas are high in fiber and contain seeds, which can increase bowel movements and pressure on the diverticula and cause them to rupture or bleed.
D. Turkey sandwich with celery sticks
Choice D reason: This is incorrect. Turkey sandwich with celery sticks is not a good menu selection for a client who has diverticulitis. Turkey sandwich may contain bread, cheese, or mayonnaise, which are high in fat and can irritate the digestive tract and worsen inflammation. Celery sticks are high in fiber and contain strings, which can increase bowel movements and pressure on the diverticula and cause them to rupture or bleed.
E. Turkey sandwich with celery sticks
This question is an excerpt from Nurse Dive's nursing test bank - NY BSN Proctored Exam. Take the full exam now
Similar Questions
A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?
A. Offer the client ice cream postoperatively.
Choice A reason: This is incorrect. Offering the client ice cream postoperatively is not an appropriate nursing action. Ice cream is high in fat and can trigger biliary colic or nausea and vomiting in a client who had a laparoscopic cholecystectomy. A laparoscopic cholecystectomy is a minimally invasive surgery to remove the gallbladder, which stores and releases bile to help digest fats.
B. Instruct the client not to lift over 4.5 kg (10 lb).
Choice B reason: This is incorrect. Instructing the client not to lift over 4.5 kg (10 lb) is not an appropriate nursing action. The client can resume normal activities, including lifting, within a few days after a laparoscopic cholecystectomy, unless otherwise advised by the surgeon. Lifting restrictions are usually applied to clients who had an open cholecystectomy, which involves a larger incision and longer recovery time.
C. Encourage ambulation once fully awake.
Choice C reason: This is the correct answer. Encouraging ambulation once fully awake is an appropriate nursing action. Ambulation can help prevent complications such as deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia, or ileus in a client who had a laparoscopic cholecystectomy. Ambulation can also promote blood circulation, wound healing, and bowel function.
D. Place the client in a supine position postoperatively.
Choice D reason: This is incorrect. Placing the client in a supine position postoperatively is not an appropriate nursing action. The client should be placed in a semi-Fowler's position (30 to 45 degrees elevation of the head of the bed) or Fowler's position (45 to 60 degrees elevation of the head of the bed) postoperatively. These positions can help reduce abdominal pressure and pain, facilitate breathing, and prevent aspiration in a client who had a laparoscopic cholecystectomy.
A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?
A. “Skeletal traction is more appropriate than skin traction for reducing a fracture.”
Choice A reason: This is the correct answer. Skeletal traction is more appropriate than skin traction for reducing a fracture because it applies a direct and continuous pull on the bone through pins, wires, or screws that are inserted into the bone. Skeletal traction can achieve greater alignment and stability of the fracture site than skin traction, which applies an indirect and intermittent pull on the bone through tapes, boots, or splints that are attached to the skin.
B. “Skeletal traction has less risk for infection than skin traction.”
Choice B reason: This is incorrect. Skeletal traction has more risk for infection than skin traction, because it involves an open wound and a foreign body that can introduce bacteria into the bone or soft tissues. Skeletal traction requires strict aseptic technique and close monitoring of the pin sites for signs of infection, such as redness, swelling, drainage, or odor.
C. “Clients with skin traction have more mobility than those with skeletal traction.”
Choice C reason: This is incorrect. Clients with skin traction have less mobility than those with skeletal traction, because they have to keep their affected limb in a fixed position and avoid any movement that can loosen or dislodge the traction device. Clients with skeletal traction can have some mobility within the limits of the prescribed weight and counterweight of the traction system.
D. “Clients with skin traction have more discomfort than those with skeletal traction.”
Choice D reason: This is incorrect. Clients with skin traction have less discomfort than those with skeletal traction, because they do not have any invasive procedure or hardware that can cause pain or irritation. Clients with skeletal traction may experience more discomfort from the insertion and removal of the pins, wires, or screws, as well as from the pressure or friction of the traction device on the bone or soft tissues.
During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect?
A. Uneven cast drying
Choice A reason: This is incorrect. Uneven cast drying is not a complication that can cause a warm area on the cast. Cast drying is a normal process that occurs after the application of a plaster or synthetic cast. It can take several hours to days, depending on the type and thickness of the cast material. Uneven cast drying can cause some areas to be weter or harder than others, but it does not affect the temperature of the cast.
B. Poor circulation
Choice B reason: This is incorrect. Poor circulation is not a complication that can cause a warm area on the cast. Poor circulation is a condition that occurs when the blood flow to the affected limb is reduced or impaired due to injury, swelling, or compression. Poor circulation can cause symptoms such as coldness, numbness, tingling, or pain in the limb. Poor circulation can also increase the risk of tissue damage or necrosis.
C. Pressure from the cast
Choice C reason: This is incorrect. Pressure from the cast is not a complication that can cause a warm area on the cast. Pressure from the cast is a condition that occurs when the cast is too tight or too loose, or when it rubs against the skin or underlying tissues. Pressure from the cast can cause symptoms such as skin irritation, blisters, ulcers, or pressure sores. Pressure from the cast can also increase the risk of infection or nerve damage.
D. Infection
Choice D reason: This is the correct answer. Infection is a complication that can cause a warm area on the cast. Infection is a condition that occurs when bacteria enter and multiply in the wound, bone, or soft tissues under the cast. Infection can cause symptoms such as fever, chills, redness, swelling, drainage, or odor from the wound site. Infection can also cause increased warmth or heat in the affected area, which can be detected through the cast. Infection can lead to serious complications such as osteomyelitis, septicemia, or amputation if not treated promptly.