Friday, May 04, 2007



A male client has just had a cholecytectomy. Which of the following statements would indicate that the client understands the post-op dietary restrictions?

A. "I can eat whatever I can tolerate."
B. "I should avoid sodas and other carbonated drinks."
C. "I need to increase my intake of high-fiber foods."
D. "I need to limit my intake of citrus foods like oranges and grapefruit."

Answer: A. For several weeks following stone removal, the client should eat a low fat diet until fat digestion is normalized. After that period, a normal diet is usually tolerated & should be encouraged.


A female post laryngectomy client, is being prepared for discharge. Which of the following questions would indicate the client has an understanding of the discharge teachings?

A. "Should I eat a high protein, low fat diet?"
B. "How long should I keep the plug for the laryngectomy tube in a disinfectant?"
C. "Which humidifier would be best to use?"
D. "How long will I aspirate food?"

Answer: C. Since the nose normally humidifies air, a client who has had a laryngectomy will require supplemental humidification. There are no dietary restrictions, and laryngectomy tubes are not plugged. There is no risk for aspiration since there is no connection between the esophagus & respiratory tract.


A female client is taking TheoDur (theophylline) to manage her asthma. Which of the following symptoms, if displayed, should the client report to the nurse?

A. Orangey-red urine
B. Heart palpitations
C. Excessive thirst
D. Weight gain

Answer: B. Adverse effects of theophylline include headache, dizziness, N&V, nervousness, epigastric pain and heart palpitations. The other options are not adverse effects of the drug.


A 80 year old male patient, is experiencing bladder incontinence. He is also at high risk for falls. Which of the following nursing measures should be included in this client's care plan?

A. Sedate as needed
B. Toilet every 1-2 hours
C. Use a chest posey restraint
D. Monitor activities every 2 hours

Answer:B. Establishing a bladder routine would be important for this patient, usually set at 2 hour intervals throughout the day & every 4 hours at night. This client should be encouraged to urinate when the urge arises. Restraints should not be used as convenience devices for fall prevention. Sedatives should be limited because they decrease the urination sensation.

No comments: