Question

The nurse is reinforcing teaching for a client who is on a full liquid diet. Which items should be appropriate for this diet? Select all that apply.

Answer 1

Correct Answers:

Jell-O
Coffee
Milkshake

Rationale :

🍮Jell-O is appropriate for a full liquid diet because it melts into liquid at body temperature and requires minimal digestion.

☕Coffee without cream or solid additives is also suitable because it is in liquid form and does not need chewing.

🥤Milkshake is included because it provides calories and protein while being fully liquid.

🥣Oatmeal and pureed green peas are not considered full liquid options because they retain bulk and require some digestion, making them closer to mechanical soft or pureed diets.

📌Core Message

Full liquid diets include items like Jell-O, coffee, and milkshakes but not foods with bulk such as oatmeal or pureed vegetables.

Answer 2

Correct Answers:

The client was recently diagnosed with diverticulitis

Rationale :

🩸Diverticulitis involves inflammation and possible rupture of diverticula, which can erode vessels and cause gastrointestinal bleeding.

🍽️Daily laxative use may cause dehydration or electrolyte imbalance, but it is not the leading cause of GI bleeding.

🍔A high-fat diet can contribute to gallstones or cardiovascular disease but does not directly cause GI bleeding.

💉Diabetes mellitus itself is not a typical cause of GI bleeding, though complications may contribute to other issues.

📌Core Message

The most likely cause of GI bleeding in this scenario is diverticulitis, not dietary choices or diabetes.

Answer 3

Correct Answers:

the client may experience temporary constipation after the procedure

Rationale :

🧴Barium enemas can cause constipation because barium is dense and may harden in the colon.

🥤Clients are usually instructed to drink fluids after the procedure to flush out residual barium.

🥗The client does not need to fast for 48 hours, only a short dietary prep before the procedure.

📅There is no need for a 30-day follow-up imaging for residual barium unless complications occur.

📌Core Message

After a barium enema, the nurse should expect temporary constipation rather than fasting or scheduled follow-ups.

Answer 4

Correct Answers:

"Classic signs include polydipsia, polyphagia, nocturia"

Rationale :

💧Polydipsia occurs due to osmotic diuresis from excess glucose in the urine.

🍽️Polyphagia results from the cells not receiving glucose despite hyperglycemia.

🌙Nocturia develops because excessive urine production continues overnight.

🩺Other options list incorrect markers such as normal glucose levels, low HbA1c, or ketoacidosis as "classic signs," which is misleading.

📌Core Message

The classic manifestations of diabetes mellitus are polydipsia, polyphagia, and nocturia, not normal glucose levels or HbA1c changes.

Answer 5

Correct Answers:

The client with a capillary blood glucose reading of 15 mg/dL and is unresponsive

Rationale :

⚠️Severe hypoglycemia at 15 mg/dL with unresponsiveness is a medical emergency and must be treated first.

💡A purple stoma indicates ischemia but is not as immediately life-threatening as hypoglycemia-induced coma.

🦶Hemoglobin A1C of 13.2% with neuropathy suggests poor long-term control but is not immediately life-threatening.

💧Profuse diarrhea with hypotension is urgent, but the lowest glucose with loss of consciousness takes top priority.

📌Core Message

The priority client is the one with severe hypoglycemia and unresponsiveness, as this is life-threatening.

Answer 6

Correct Answers:

Dumping syndrome

Rationale :

🍽️Dumping syndrome is a common complication after gastrectomy due to rapid emptying of stomach contents into the small intestine.

💨This leads to diarrhea, weakness, dizziness, and hypoglycemia after meals.

📉Other options like umbilical hernia, gallstones, or peptic ulcers are not as directly associated with post-gastrectomy recovery.

🩺Monitoring for this helps guide dietary education and lifestyle changes.

📌Core Message

After a gastrectomy, the major complication to monitor for is dumping syndrome.

Answer 7

Correct Answers:

Increase fluids

Rationale :

💧Barium swallow leaves residue in the GI tract that can harden and cause constipation.

🥤Encouraging increased fluid intake helps flush barium out of the intestines.

🚫Clients are not advised to assume prone position or expect diarrhea after the procedure.

🥗Increasing fiber is generally good but not as critical as hydration for this situation.

📌Core Message

After a barium swallow, the nurse should encourage increased fluid intake to prevent constipation.

Answer 8

Correct Answers:

Protect the client's airway

Rationale :

🛡️When a client is actively vomiting, the priority is airway protection to prevent aspiration.

💊Administering antiemetics helps but does not address the immediate airway risk.

🧪NG tube insertion or IV fluids may be needed later but are not first actions.

⚠️Airway compromise can quickly lead to respiratory distress or aspiration pneumonia.

📌Core Message

In an actively vomiting client, the first priority is to protect the airway before any other intervention.

Answer 9

Correct Answers:

Check the client's blood sugar

Rationale :

🩸A headache and diaphoresis in a diabetic patient suggests hypoglycemia.

📊The first step is to confirm this by checking the blood glucose level.

💉Reviewing insulin administration or checking for ketones are secondary actions after confirming glucose status.

💊Giving pain medication without ruling out hypoglycemia would miss the urgent underlying cause.

📌Core Message

When a diabetic client is sweating and has a headache, the nurse should check blood glucose first to confirm hypoglycemia.

Answer 10

Correct Answers:

Liver
Gallbladder
Bile duct

Rationale :

🩺The hepatobiliary system consists of the liver, gallbladder, and bile ducts, which work together in bile production and secretion.

🍴The esophagus is part of the digestive tract but not the hepatobiliary system.

🍎The colon is part of the large intestine and is unrelated to bile flow.

🔄The hepatobiliary system plays a crucial role in fat digestion and metabolism.

📌Core Message

The hepatobiliary system includes the liver, gallbladder, and bile ducts, not digestive structures like the esophagus or colon.

RN NUR-215 Med-Surg 2025 Exam-4

No.

1 :
The nurse is reinforcing teaching for a client who is on a full liquid diet. Which items should be appropriate for this diet? Select all that apply.

2 :
The nurse is admitting a client with a diagnosis of gastrointestinal (GI) bleeding. After collecting the admission history, what should the nurse identify as the most likely cause for this client's bleeding?

3 :
The nurse is caring for a client with diverticulosis. The healthcare provider has ordered a barium enema. The nurse understands that:

4 :
The nursing instructor is educating her students about the clinical manifestations of diabetes mellitus (DM). The nursing instructor will know the students understand the concept when they make which statement?

5 :
Which client is priority?

6 :
Which complication should the nurse monitor for while caring for a client post gastrectomy?

7 :
The nurse is preparing a client for a barium swallow. What information should the nurse include in the client teaching for post-procedure?

8 :
Which of the following is priority for the nurse caring for an actively vomiting client?

9 :
The nurse is caring for a client with diabetes mellitus type 2. The client complains of a headache and is diaphoretic. Which action should the nurse take first?

10 :
The nurse is reviewing structures in the hepatobiliary system. Which structures are found in this system? Select all that apply

RN NUR-215 Med-Surg 2025 Exam-4

No.

1 : The nurse is reinforcing teaching for a client who is on a full liquid diet. Which items should be appropriate for this diet? Select all that apply.

2 : The nurse is admitting a client with a diagnosis of gastrointestinal (GI) bleeding. After collecting the admission history, what should the nurse identify as the most likely cause for this client's bleeding?

3 : The nurse is caring for a client with diverticulosis. The healthcare provider has ordered a barium enema. The nurse understands that:

4 : The nursing instructor is educating her students about the clinical manifestations of diabetes mellitus (DM). The nursing instructor will know the students understand the concept when they make which statement?

5 : Which client is priority?

6 : Which complication should the nurse monitor for while caring for a client post gastrectomy?

7 : The nurse is preparing a client for a barium swallow. What information should the nurse include in the client teaching for post-procedure?

8 : Which of the following is priority for the nurse caring for an actively vomiting client?

9 : The nurse is caring for a client with diabetes mellitus type 2. The client complains of a headache and is diaphoretic. Which action should the nurse take first?

10 : The nurse is reviewing structures in the hepatobiliary system. Which structures are found in this system? Select all that apply

1 :
The nurse is reinforcing teaching for a client who is on a full liquid diet. Which items should be appropriate for this diet? Select all that apply.

2 :
The nurse is admitting a client with a diagnosis of gastrointestinal (GI) bleeding. After collecting the admission history, what should the nurse identify as the most likely cause for this client's bleeding?

3 :
The nurse is caring for a client with diverticulosis. The healthcare provider has ordered a barium enema. The nurse understands that:

4 :
The nursing instructor is educating her students about the clinical manifestations of diabetes mellitus (DM). The nursing instructor will know the students understand the concept when they make which statement?

5 :
Which client is priority?

6 :
Which complication should the nurse monitor for while caring for a client post gastrectomy?

7 :
The nurse is preparing a client for a barium swallow. What information should the nurse include in the client teaching for post-procedure?

8 :
Which of the following is priority for the nurse caring for an actively vomiting client?

9 :
The nurse is caring for a client with diabetes mellitus type 2. The client complains of a headache and is diaphoretic. Which action should the nurse take first?

10 :
The nurse is reviewing structures in the hepatobiliary system. Which structures are found in this system? Select all that apply