ATI Med-Surg Test Bank
1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following
... [Show More] instructions should the nurse include in the teaching?
1) Take temperature once a day.
Answer Rationale:
The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is present due to the client’s altered immune system.
INCORRECT
2) Wash the armpits and genitals with a gentle cleanser daily.
Answer Rationale:
The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and genitals twice daily.
INCORRECT
3) Change the litter boxes while wearing gloves.
Answer Rationale:
The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life threatening to a client who has HIV.
INCORRECT
4) Wash dishes in warm water.
Answer Rationale:
The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.
2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?
1) Provide humidified oxygen.
Answer Rationale:
Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
Answer Rationale:
Performing chest physiotherapy mobilizes secretions but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Answer Rationale:
Prelubricating the suction catheter tip with sterile saline helps to ease the insertion of the catheter, producing less trauma. However, it has no effect on the tenacity of the client's secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on the tenacity of the client's secretions.
3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the lower extremities is a contraindication for leg massage.
2) Obtain a pair of slipper socks for the client.
Answer Rationale:
Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.
INCORRECT
3) Increase the client's oral fluid intake.
Answer Rationale:
Increasing the client's fluid intake will not increase circulation to an area an occlusion impairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a contraindication for applying a heating pad.
4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
INCORRECT
1) Emesis of 100 mL
Answer Rationale:
The nurse should recognize postoperative nausea is a complication related to the administration of anesthesia and should treat the nausea with anti-emetics and provide supportive measures; however, it is not the priority finding.
INCORRECT
2) Oral temperature of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and encourage deep breathing, coughing, and fluid intake (if permitted); however, it is not the priority finding to report. The increase in temperature is likely due to decreased respiratory effort related to the use of anesthesia and should clear with pulmonary hygiene.
3) Thick, red-colored urine
Answer Rationale:
The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be reported to the provider immediately.
INCORRECT
4) Pain level of 4 on a 0 to 10 rating scale
Answer Rationale:
The nurse should assess for and treat postoperative pain which is an expected finding in the postoperative client; however it is not the priority finding to report. Specific pain, such as bladder spasms, may indicate complications however and should be reported to the provider.
5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?
1) Shivering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can cause the client’s temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A manifestation of infection is hyperthermia.
INCORRECT
3) Burns
Answer Rationale:
Burns are associated with the improper use of heating pads, not hypothermia blankets.
INCORRECT
4) Hypervolemia
Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk associated with hyperthermia due to fluid loss.
6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
INCORRECT
1) "I will carry a complex carbohydrate snack with me when I exercise."
Answer Rationale:
The nurse should reinforce that the client should carry a simple carbohydrate such as hard candy or glucose tablets for use during exercise if the client becomes hypoglycemic.
INCORRECT
2) "I should exercise first thing in the morning before eating breakfast."
Answer Rationale:
The nurse should reinforce that exercise should follow a meal. Exercising first thing in the morning on an empty stomach places the client at risk for hypoglycemia.
INCORRECT
3) "I should avoid injecting insulin into my thigh if I am going to go running."
Answer Rationale:
The nurse should reinforce that the client should avoid injecting insulin into an area that will soon be exercised to avoid increasing the absorption rate of the insulin.
4) "I will not exercise if my urine is positive for ketones."
Answer Rationale:
The nurse should reinforce that exercise should be avoided if ketones are present in the urine as this indicates an elevated blood glucose level or ketoacidosis.
7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?
1) Cover the client's wound with a moist, sterile dressing.
Answer Rationale:
According to evidence-based practice, the nurse's first action should be to cover the wound with a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the tissue moist.
INCORRECT
2) Have the client lie supine with knees flexed.
Answer Rationale:
The nurse should have the client lie supine with knees flexed to promote adequate circulation to the vital organs. However, evidence-based practice indicates that this is not the first action the nurse should take.
INCORRECT
3) Check the client's vital signs.
Answer Rationale:
The nurse should check the client’s vital signs because the client is at risk for shock following wound evisceration. However, evidence-based practice indicates that this is not the first action the nurse should take.
INCORRECT
4) Inform the client about the need to return to surgery.
Answer Rationale:
The nurse should inform the client about the need to return to emergency surgery to preserve the bowel and prevent complications. However, evidence-based practice indicates that this is not the first action the nurse should take.
8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?
INCORRECT
1) Cool, clammy skin
Answer Rationale:
The nurse should expect to find warm, flushed skin in a client who is experiencing metabolic acidosis.
2) Hyperventilation
Answer Rationale:
The nurse should expect to find hyperventilation in a client who is experiencing metabolic acidosis. The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations.
INCORRECT
3) Increased blood pressure
Answer Rationale:
The nurse should expect to find hypotension in a client who is experiencing metabolic acidosis.
INCORRECT
4) Bradycardia
Answer Rationale:
The nurse should expect to find tachycardia in a client who is experiencing metabolic acidosis.
9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?
1) Avoid bending at the waist.
Answer Rationale:
The nurse should reinforce that the client should avoid bending at the waist as this increases intraocular pressure; the client should be instructed to flex the knees and crouch instead.
INCORRECT
2) Remove the eye shield at bedtime.
Answer Rationale:
The client should be instructed to use an eye shield when retiring for the night to protect the eye from accidental injury, such as rubbing that may occur when the client is asleep.
INCORRECT
3) Limit the use of laxatives if constipated.
Answer Rationale:
The client should be encouraged to use laxatives in the event of constipation to avoid straining while attempting to have a bowel movement. Straining increases intraocular pressure and can cause damage to the surgical site.
INCORRECT
4) Seeing flashes of light is an expected finding following extraction.
Answer Rationale:
The nurse should instruct the client that flashes of light indicates a complication of cataract extraction, and should be reported to the provider.
10. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
INCORRECT
1) Suggest that the client rests before eating the meal.
Answer Rationale:
The nurse should encourage frequent rest periods for the client who has heart failure, as dyspnea and fluid overload increases the workload to consume adequate nutrition; however, another action is the priority.
INCORRECT
2) Request a dietary consult.
Answer Rationale:
The nurse should consider obtaining a dietary consult for the client who has heart failure to provide nutritional evaluation and counseling; however, another action is the priority.
3) Check the client's vital signs.
Answer Rationale:
When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision.
INCORRECT
4) Request an order for an antiemetic.
Answer Rationale:
The nurse should request antiemetics for the client who is experiencing nausea in order to maintain client comfort and nutritional intake; however, another action is the priority.
11. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?
INCORRECT
1) Sanguineous
Answer Rationale:
Sanguineous indicates fresh bleeding.
INCORRECT
2) Serous
Answer Rationale:
Serous describes clear, watery plasma.
INCORRECT
3) Serosanguineous
Answer Rationale:
Serosanguineous describes watery drainage that has some blood in it.
4) Purulent
Answer Rationale:
Purulent describes drainage that is thick yellow, green, or brown in color.
12. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
Answer Rationale:
The nurse should administer analgesics prior to initiating any exercise program for the client who has had joint arthroplasty. It is important that analgesics are administered in time for the medication to work before the start of the exercise program to ensure discomfort is minimized.
INCORRECT
2) Place the client’s affected leg into the CPM machine with the machine in the flexed position.
Answer Rationale:
The nurse should place the client’s leg in the CPM machine while the machine is in the extended position to allow for proper fit and comfort.
INCORRECT
3) Place the client into a high Fowler’s position when initiating the CPM exercises.
Answer Rationale:
The nurse should limit the elevation of the client’s head of the bed to no more than 20 degrees while the client is using the CPM machine to avoid extreme flexion of the hip and patient discomfort.
INCORRECT
4) Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer Rationale:
The nurse should align the joints of the CPM machine with the client’s knee joint to ensure safe operation of the unit and prevent injury to the client.
13. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being delivered to the tissues.
14. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?
INCORRECT
1) Take the client's temperature.
Answer Rationale:
The nurse should take the client's temperature to ensure the client is afebrile to prevent infection and brain dysfunction; however, another finding is the priority.
INCORRECT
2) Place a dressing under the client's nose.
Answer Rationale:
The nurse should place a dressing under the client's nose to measure and collect the amount of drainage; however, another finding is the priority.
INCORRECT
3) Notify the charge nurse.
Answer Rationale:
The nurse should notify the charge nurse about the client’s condition; however, another finding is the priority.
4) Test the drainage for glucose.
Answer Rationale:
The greatest risk to a client who has a basal skull fracture is injury from cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage for glucose.
15. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
INCORRECT
1) Monitor for elevated blood pressure.
Answer Rationale:
Elevated blood pressure is a serious manifestation of autonomic dysreflexia. However, it is not a causative agent.
INCORRECT
2) Provide analgesia for headaches.
Answer Rationale:
A severe headache is one of the manifestations of autonomic dysreflexia. However, it is not a causative agent.
3) Prevent bladder distention.
Answer Rationale:
Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position
INCORRECT
4) Elevate the client's head.
Answer Rationale:
A sudden change in position can trigger autonomic dysreflexia.
16. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?
INCORRECT
1) Hot flashes
Answer Rationale:
Hot flashes are indicative of hormonal changes such as menopause.
INCORRECT
2) Recurrent urinary tract infections
Answer Rationale:
Urinary tract infections are related to the kidney function and can be related to not drinking enough water.
INCORRECT
3) Blood in the stool
Answer Rationale:
Blood in the stool can be a sign of gastrointestinal disease.
4) Abnormal vaginal bleeding
Answer Rationale:
The nurse should expect the client to experience abnormal vaginal bleeding, including postmenopausal bleeding and bleeding between normal periods. Abnormal vaginal bleeding is the most common finding in endometrial cancer in premenopausal women.
17. A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
Answer Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is for the nurse to monitor the client's altered level of consciousness. A fracture of one of the long bones of the body places the client is at risk for fat embolism, which causes a decrease in oxygenation and alters the client's level of consciousness.
INCORRECT
2) Oral temperature of 37.7° C (100° C)
Answer Rationale:
The nurse should monitor the client's temperature, as this can be a risk for infection or a fat embolism; however, another action is the priority.
INCORRECT
3) Muscle spasms
Answer Rationale:
The nurse should observe the client for muscle spasms as a manifestation following this type of procedure; however, another action is the priority.
INCORRECT
4) Headache
Answer Rationale:
The nurse should observe the client for a headache to address his pain; however, another action is the priority.
18. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?
1) Abdomen is distended
Answer Rationale:
When using the airway, breathing, circulation approach to client care, the nurse should recognize the presence of abdominal distention has the potential to compromise the client’s respiratory status as the distention increases abdominal pressure on the diaphragm and impairs ventilation. This is the priority finding for the nurse to report.
INCORRECT
2) Chest tube drainage of 70 mL in the last hour
Answer Rationale:
The nurse should monitor the drainage from the chest tube system for quantity and characteristics of the drainage, as increases in drainage or the presence of bright red drainage may indicate bleeding. 70 mL of drainage in an hour is within the accepted limits during the first 3 hours postoperatively; therefore, another finding is the priority.
INCORRECT
3) Subcutaneous emphysema is noted to the left chest wall
Answer Rationale:
The nurse should monitor and report subcutaneous emphysema in a client who has a chest tube as this may be an indication of air leaking from the lung into the tissues; however, another finding is the priority.
INCORRECT
4) Pain level of 6 on a 0 to 10 scale
Answer Rationale:
The nurse should assess and manage pain in the postoperative client. Uncontrolled pain results in prolonged healing time, and decreased depth of respirations which might result in pneumonia; however, another finding is the priority.
19. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?
INCORRECT
1) Change the ostomy pouch daily.
Answer Rationale:
The ostomy pouch is changed every 3 to 7 days.
2) Empty the ostomy pouch when it is 2/3 full.
Answer Rationale:
The ileal conduit cannot store urine the way the bladder did; urine will flow continuously into a collecting device. Emptying the device when the pouch is 2/3 full will prevent leakage, skin irritation, and infection.
INCORRECT
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
Answer Rationale:
The opening of the ostomy seal should be trimmed to be 1/16 to 1/8 in. wider than the stoma. A larger opening allows urine to collect on the skin leading to skin breakdown.
INCORRECT
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer Rationale:
When changing the ostomy pouch, the peristomal skin should be washed and dried completely. Any remaining moisture or lotion on the skin will prevent adherence of the pouch causing leakage of urine.
20. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?
INCORRECT
1) Position the client supine while in bed.
Answer Rationale:
The nurse should place the client in a semi-Fowler's position to decrease intracranial pressure, which could lead to a cerebrospinal fluid leak.
2) Change the nasal drip pad as needed.
Answer Rationale:
The nurse should change the nasal drip pad as needed because the client will have nasal packing and bloody nasal drainage until the surgical site is healed.
INCORRECT
3) Encourage frequent brushing of teeth.
Answer Rationale:
The nurse should inform the client not to brush his teeth, because it will interfere with the healing process.
INCORRECT
4) Encourage the client to cough every 2 hr following surgery.
Answer Rationale:
The nurse should instruct the client to not cough, because it may interfere with the healing process and may lead to cerebrospinal fluid leak.
21. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?
INCORRECT
1) To provide analgesia
Answer Rationale:
Although aspirin is used to provide analgesia for mild to moderate pain, the nurse should recognize that it is prescribed to this client for a different therapeutic effect.
INCORRECT
2) To reduce inflammation
Answer Rationale:
Although aspirin is used to reduce inflammation for illnesses such as osteoarthritis, the nurse should recognize that it is prescribed to this client for a different therapeutic effect.
3) To prevent blood clotting
Answer Rationale:
Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the nurse should instruct the client the aspirin is prescribed for clients who have coronary artery disease to prevent myocardial infarction caused by clots in the coronary arteries.
INCORRECT
4) To prevent fever
Answer Rationale:
Although aspirin is used as an antipyretic agent for adult clients, the nurse should recognize that it is prescribed to this client for a different therapeutic effect. Aspirin should not be used to treat fever for client suspected to have meningitis.
22. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?
1) Loss of peripheral vision
Answer Rationale:
The nurse should expect to find the client experiencing a gradual loss of peripheral vision with a narrowing of the visual field with open-angle glaucoma.
INCORRECT
2) Headache
Answer Rationale:
Headache is associated with acute angle-closure glaucoma.
INCORRECT
3) Halos around lights
Answer Rationale:
A halo around lights with blurred vision is associated with acute angle-closure glaucoma.
INCORRECT
4) Discomfort in the eyes
Answer Rationale:
Discomfort in the eyes is associated with acute angle-closure glaucoma.
23. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?
INCORRECT
1) Weight loss of 3% of total body weight.
Answer Rationale:
The nurse should monitor a weight loss of 3% of total body weight, which indicates mild fluid volume deficit; however, another finding is the priority.
INCORRECT
2) Blood glucose 150 mg/dL
Answer Rationale:
The nurse should monitor a blood glucose of 150 mg/dL, which indicates mild hyperglycemia; however, another finding is the priority.
3) Potassium 2.5 mEq/L
Answer Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL. In the presence of fluid volume deficit, potassium depletion can occur. Complications from hypokalemia include cardiac and respiratory manifestations.
INCORRECT
4) Urine specific gravity 1.035
Answer Rationale:
The nurse should monitor a urine specific gravity of 1.035, which indicates concentrated urine; however, another finding is the priority.
24. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?
INCORRECT
1) "I should increase my intake of protein and vitamin C."
Answer Rationale:
The client should increase her intake of protein and vitamin C to promote wound healing.
INCORRECT
2) "I will no longer have menstrual periods."
Answer Rationale:
Following a total abdominal hysterectomy the client may have vaginal discharge for a short period of time, but the client will no longer have menstrual periods.
INCORRECT
3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort."
Answer Rationale:
The client who has had a vaginal repair may experience discomfort during intercourse. A water-based lubricant may help to reduce the discomfort.
4) "I will take a tub bath instead of a shower."
Answer Rationale:
To reduce the risk of infection, the client should avoid tub baths following a total abdominal hysterectomy.
25. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?
INCORRECT
1) Loosen the knots on the ropes if the client is experiencing pain.
Answer Rationale:
The knots should never be loosened on the ropes. Doing this will unsecure the traction and possibly injure the client.
2) Ensure the client’s weights are hanging freely from the bed.
Answer Rationale:
The nurse should ensure that the client’s weights are hanging freely from the bed to maintain the client in proper body alignment and should never be removed without a provider prescription or the development of a life-threatening situation that requires removal.
INCORRECT
3) Check the client’s bony prominences every 12 hr.
Answer Rationale:
The client’s bony prominences and skin should be checked every 8 hr for skin breakdown, irritation, and inflammation.
INCORRECT
4) Cleanse the client’s pin sites with povidone-iodine.
Answer Rationale:
The nurse should cleanse the client’s pin sites with chlorhexidine solution to keep the sites clean and free from bacteria.
26. A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
Answer Rationale:
Although taking iron supplements with food can decrease adverse effects, it also drastically reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron is most effective when supplements are taken in between meals.
INCORRECT
2) Limit intake of Vitamin C while taking this medication.
Answer Rationale:
Taking Vitamin C (ascorbic acid) at the same time as taking iron can enhance the absorption of iron, but it can increase the incidence of adverse effects. However, there is no reason for the client to limit overall intake of ascorbic acid.
INCORRECT
3) Take this medication with milk.
Answer Rationale:
The nurse should instruct the client not to take iron with milk because it decreases the absorption of the iron.
INCORRECT
4) Limit intake of whole grains while taking this medication.
Answer Rationale:
The nurse should instruct the client to increase consumption of high-fiber foods, such as whole grains, while taking iron to prevent constipation.
27. A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
Answer Rationale:
Although taking iron supplements with food can decrease adverse effects, it also drastically reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron is most effective when supplements are taken in between meals.
INCORRECT
2) Limit intake of Vitamin C while taking this medication.
Answer Rationale:
Taking Vitamin C (ascorbic acid) at the same time as taking iron can enhance the absorption of iron, but it can increase the incidence of adverse effects. However, there is no reason for the client to limit overall intake of ascorbic acid. [Show Less]