Nursing Elites

1. A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has best understanding of the dietary measures to follow of the client states an intention to increase intake of:

• A. Pork
• B. Milk
• C. Chicken
• D. Broccoli

Correct answer: A

Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Broccoli contains vitamins C, E, and K and folic acid.

2. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

• A. Inspect skin around the T tube daily for irritation.
• B. Irrigate the T tube every 4 hours to maintain patency.
• C. Maintain the client in a supine position while the T tube is in place.
• D. Keep the T tube clamped except during mealtimes.

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

3. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

• A. Increase the amount of sodium in the diet.
• B. Limit the amount of fluids consumed.
• C. Encourage frequent ambulation.
• D. Administer magnesium antacids.

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

4. Which of the following types of diets is implicated in the development of diverticulosis?

• A. Low-fiber diet
• B. High-fiber diet
• C. High-protein diet
• D. Low-carbohydrate diet

Correct answer: A

Rationale: A low-fiber diet is implicated in the development of diverticulosis because it leads to harder stools and increased pressure in the colon. The lack of fiber results in decreased bulk and slower transit time, predisposing individuals to constipation and the formation of diverticula. High-fiber diets, on the other hand, promote regular bowel movements and help prevent diverticular disease. High-protein and low-carbohydrate diets do not have a direct association with diverticulosis.

5. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?

• A. I should take my antacid before I take my other medications.
• B. I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.
• C. My antacid will be most effective if I take it whenever I experience stomach pains.
• D. It is best for me to take my antacid 1 to 3 hours after meals.

Correct answer: D

Rationale: It is best for the client to take the antacid 1 to 3 hours after meals to ensure effectiveness.

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