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NurseDive Free Nursing Practice Question
A nurse is planning to reinforce teaching with a client who has hemorrhoids. Which of the following information should the nurse plan to include in the instructions?
A. Follow a high-fiber diet to establish bowel regularity.
Reason: Following a high-fiber diet to establish bowel regularity is an appropriate instruction for a client who has hemorrhoids, as it helps to soften stools and reduce straining and pressure on hemorrhoids.
B. Use a stimulant laxative to prevent constipation.
Reason: Using a stimulant laxative to prevent constipation is not an appropriate instruction for a client who has hemorrhoids, as it may cause diarrhea, dehydration, or electrolyte imbalance.
C. Clean the anal area after bowel movements with alcohol-based wipes.
Reason: Cleaning the anal area after bowel movements with alcohol-based wipes is not an appropriate instruction for a client who has hemorrhoids, as it may irritate, dry, or damage hemorrhoidal tissue.
D. Limit the intake of fruit to prevent loose stools.
Reason: Limiting the intake of fruit to prevent loose stools is not an appropriate instruction for a client who has hemorrhoids, as fruit is a good source of fiber and fluid that can help prevent constipation and hemorrhoids.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 3. Take the full exam now
Full Explanation
Choice A Reason: Following a high-fiber diet to establish bowel regularity is an appropriate instruction for a client who has hemorrhoids, as it helps to soften stools and reduce straining and pressure on hemorrhoids.
Choice B Reason: Using a stimulant laxative to prevent constipation is not an appropriate instruction for a client who has hemorrhoids, as it may cause diarrhea, dehydration, or electrolyte imbalance.
Choice C Reason: Cleaning the anal area after bowel movements with alcohol-based wipes is not an appropriate instruction for a client who has hemorrhoids, as it may irritate, dry, or damage hemorrhoidal tissue.
Choice D Reason: Limiting the intake of fruit to prevent loose stools is not an appropriate instruction for a client who has hemorrhoids, as fruit is a good source of fiber and fluid that can help prevent constipation and hemorrhoids.
Similar Questions
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 310 mg/dL instead of 103 mg/dL and administered the insulin dose appropriate for a reading over 300 mg/dL. Which of the following actions should the nurse identify as the priority?
A. Call the RN supervisor.
Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.
B. Complete an incident report.
Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.
C. Check the blood glucose level.
Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.
D. Give the client 15 to 20 g of carbohydrate.
Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.
Full Explanation
Choice A Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.
Choice B Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.
Choice C Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.
Choice D Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.
A client's stool is clay in color. What additional information should the nurse obtain from this client? Select all that apply.
A. History of alcohol abuse
Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.
B. Intolerance to fatty foods
Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.
C. Pain in the RUQ radiating to the shoulder.
Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.
D. Pain in the McBurney's point
Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.
E. Bleeding ulcer
Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.
Full Explanation
Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.
Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.
Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.
Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.
Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.
A nurse is caring for a client who had a cholecystectomy and has a T-tube drain. Which of the following actions should the nurse take?
A. Apply a transparent dressing to the drain site.
Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.
B. Clamp the tubing when the client ambulates.
Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.
C. Place the client into Fowler's position.
Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.
D. Secure the tubing to the client's gown.
Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.
Full Explanation
Choice A Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.
Choice B Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.
Choice C Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.
Choice D Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.