Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the
nurse include in the teaching?
A. Bear down hard when defecating.
Choice A reason: This is incorrect. Bearing down hard when defecating can cause straining, which can worsen constipation and increase the risk of hemorrhoids, anal fissures, or rectal prolapse. The nurse should advise the client to relax and avoid straining when defecating.
B. Limit activity.
Choice B reason: This is incorrect. Limiting activity can reduce bowel motility and contribute to constipation. The nurse should encourage the client to increase physical activity, such as walking, swimming, or cycling, to stimulate bowel movements and improve overall health.
C. Increase dietary intake of raw vegetables.
Choice C reason: This is the correct answer. Increasing dietary intake of raw vegetables can help prevent and treat constipation. Raw vegetables are rich in fiber, which can add bulk and softness to the stool and make it easier to pass. The nurse should recommend the client to eat at least 25 grams of fiber per day from various sources, such as fruits, grains, nuts, seeds, and legumes.
D. Drink four to five glasses of water daily.
Choice D reason: This is incorrect. Drinking four to five glasses of water daily may not be enough to prevent or treat constipation. Water can help hydrate the stool and make it softer and easier to pass. However, the amount of water needed varies depending on the individual's age, weight, activity level, and health status. The nurse should advise the client to drink enough water to keep the urine clear or pale yellow and to avoid dehydration. The nurse should also caution the client to limit or avoid caffeinated or alcoholic beverages, which can have a diuretic effect and cause fluid loss.
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 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
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.