Med Surg 1 Exam 3
Questions and Answers
1. The nurse instructs a client about how to increase folic acid in the diet.
The nurse determines teaching is effective if the client makes which
statement?
a) "I like oatmeal for breakfast."
b) "My favorite lunch is a spinach salad."
c) "I will eat more grapes, apples, and bananas each day."
d) "I will eat more chicken.": b) "My favorite lunch is a spinach salad."
spinach contains 108 mg of folic acid per half-cup serving; other folate-rich
sourcesinclude organ meats, broccoli, asparagus, milk, orange juice, wheat
germ and Grape-Nuts
2. The nurse cares for a client with a nasogastric tube in place. The
client reports discomfort in the back of the throat. Which action by
the nurse isBEST?
a) Move the tube out 2 inches
,b) Change feedings to full liquids
c) Reinsert tube into other nostril
d) Spray with viscous lidocaine solution: d) Spray with viscous lidocaine
solution
viscous lidocaine is a local anesthetic; spraying it on the irritated surface may
relievethe discomfort in the back of the client's throat; tube only repositioned
if the tube isn'tdraining after irrigation
3. The nurse gives discharge instructions to the family of a patient
diagnosed with hepatic encephalopathy. The nurse determines further
teaching is neces- sary if the family makes which of the following
statements?
a) We should contact the physician if Dad is restless at night."
b) "Cephulac will cause Dad to have 2-3 stools per day."
c) "Dad should eat meat at every meal."
d) "Cephulac may cause bloating and cramps.": c) "Dad should eat meat at
everymeal."
low-protein, high-calorie diet for clients with hepatic encephalopathy;
instruct familyto observe for and report any mental status changes; hepatic
encephalopathy occurswith profound liver disease and results from the
accumulation of ammonia in the blood; earliest s/s are mental changes, such
,as exhibiting periods of lethargy and euphoria and progressing to coma
, 4. The home care nurse visits a client with a diagnosis of ulcerative colitis.
The client complains of perineal irritation due to frequent stools. Which
suggestionby the nurse is BEST?
a) Apply a heat lamp to the perineal area three times per day
b) Use protective plastic bed pads
c) Clean the perineal area with soap and water after each bowel
movement
d) Increase roughage in the diet to prevent the frequent stools: c) Clean
theperineal area with soap and water after each bowel movement
keeps the skin free of stool; important to keep perineal area clean and dry; sitz
baths; apply petroleum jelly or vitamin A and D ointment; low residue diet
recommended
5. The nurse instructs a client about appropriate foods for a high-protein
diet.The nurse determines teaching is effective if the client chooses which
menu?
a) Chef salad, crackers, and iced tea
b) Broiled fish, cream of tomato soup topped with grated cheese, and
custard
c) Peanut butter and jelly sandwich, chips, and fruit drink
d) Turkey sandwich with lettuce and tomato, potato salad, and milk: b)
Questions and Answers
1. The nurse instructs a client about how to increase folic acid in the diet.
The nurse determines teaching is effective if the client makes which
statement?
a) "I like oatmeal for breakfast."
b) "My favorite lunch is a spinach salad."
c) "I will eat more grapes, apples, and bananas each day."
d) "I will eat more chicken.": b) "My favorite lunch is a spinach salad."
spinach contains 108 mg of folic acid per half-cup serving; other folate-rich
sourcesinclude organ meats, broccoli, asparagus, milk, orange juice, wheat
germ and Grape-Nuts
2. The nurse cares for a client with a nasogastric tube in place. The
client reports discomfort in the back of the throat. Which action by
the nurse isBEST?
a) Move the tube out 2 inches
,b) Change feedings to full liquids
c) Reinsert tube into other nostril
d) Spray with viscous lidocaine solution: d) Spray with viscous lidocaine
solution
viscous lidocaine is a local anesthetic; spraying it on the irritated surface may
relievethe discomfort in the back of the client's throat; tube only repositioned
if the tube isn'tdraining after irrigation
3. The nurse gives discharge instructions to the family of a patient
diagnosed with hepatic encephalopathy. The nurse determines further
teaching is neces- sary if the family makes which of the following
statements?
a) We should contact the physician if Dad is restless at night."
b) "Cephulac will cause Dad to have 2-3 stools per day."
c) "Dad should eat meat at every meal."
d) "Cephulac may cause bloating and cramps.": c) "Dad should eat meat at
everymeal."
low-protein, high-calorie diet for clients with hepatic encephalopathy;
instruct familyto observe for and report any mental status changes; hepatic
encephalopathy occurswith profound liver disease and results from the
accumulation of ammonia in the blood; earliest s/s are mental changes, such
,as exhibiting periods of lethargy and euphoria and progressing to coma
, 4. The home care nurse visits a client with a diagnosis of ulcerative colitis.
The client complains of perineal irritation due to frequent stools. Which
suggestionby the nurse is BEST?
a) Apply a heat lamp to the perineal area three times per day
b) Use protective plastic bed pads
c) Clean the perineal area with soap and water after each bowel
movement
d) Increase roughage in the diet to prevent the frequent stools: c) Clean
theperineal area with soap and water after each bowel movement
keeps the skin free of stool; important to keep perineal area clean and dry; sitz
baths; apply petroleum jelly or vitamin A and D ointment; low residue diet
recommended
5. The nurse instructs a client about appropriate foods for a high-protein
diet.The nurse determines teaching is effective if the client chooses which
menu?
a) Chef salad, crackers, and iced tea
b) Broiled fish, cream of tomato soup topped with grated cheese, and
custard
c) Peanut butter and jelly sandwich, chips, and fruit drink
d) Turkey sandwich with lettuce and tomato, potato salad, and milk: b)
