In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Correct Answer: A

Rationale: In nursing practice, assessing stool characteristics is crucial as it provides valuable insights into a patient's gastrointestinal health. Option A, reporting daily black, sticky stool, should be communicated to the healthcare provider immediately as it may indicate the presence of upper gastrointestinal bleeding, possibly from the stomach or upper small intestine. This sign requires urgent evaluation and intervention to prevent further complications. Options B, C, and D describe variations of normal stool characteristics, which do not raise immediate concerns. Dark brown stool (Option B) is a common color variation influenced by diet and transit time. Firm brown stool every other day (Option C) may indicate a normal bowel pattern for some individuals. Soft light brown stool twice a day (Option D) can also be within the spectrum of normal stool consistency. Educationally, this question highlights the importance of recognizing abnormal findings during a health assessment. Nurses need to differentiate between normal and abnormal stool characteristics to identify potential health issues promptly. Understanding these distinctions is essential for providing safe and effective patient care.

Correct Answer: B

Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 150 ml/hr. To determine the correct infusion rate, we need to consider the total volume to be infused (50 ml) over the specified time (20 minutes). First, convert 20 minutes to hours (20/60 = 1/3 hr). Then, divide the total volume by the time to get the rate: 50 ml / 1/3 hr = 150 ml/hr. Option A) 75 ml/hr is incorrect because it would infuse the medication at half the required rate, which could lead to underdosing. Option C) 225 ml/hr and D) 300 ml/hr are incorrect as they would infuse the medication at a rate higher than prescribed, potentially causing adverse effects or complications for the patient. In an educational context, this question tests the nurse's ability to calculate intravenous infusion rates accurately, which is crucial in delivering safe and effective patient care. Nurses must understand medication dosages, dilutions, and infusion rates to prevent medication errors and ensure patient safety. Mastering these calculations is essential for nurses working in various healthcare settings to provide quality care and improve patient outcomes.

Correct Answer: B

Rationale: In the context of nursing care for a Jehovah's Witness client, the correct concern for planning care is option B: Blood transfusions are forbidden. This is because Jehovah's Witnesses refuse blood transfusions based on their religious beliefs. It is crucial for nurses to respect and adhere to the client's wishes regarding blood products to provide culturally competent care. Option A, autopsy of the body being prohibited, is not a primary concern in immediate care planning for a Jehovah's Witness client. While this is a belief in the faith, it does not have the same urgent implications as the prohibition of blood transfusions. Option C, alcohol use in any form is not allowed, is not directly related to the urgent care planning needs of a Jehovah's Witness client and is not a significant concern compared to the prohibition of blood transfusions. Option D, a vegetarian diet must be followed, is also not as critical as the prohibition of blood transfusions in the context of immediate care planning for a Jehovah's Witness client. While dietary considerations are important, they do not pose the same level of immediate risk as the refusal of blood transfusions. Educationally, this question highlights the importance of understanding and respecting diverse cultural and religious beliefs in nursing practice. Nurses must be knowledgeable about different faith traditions to provide individualized, respectful care that aligns with the client's values and beliefs.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 63 ml/hour. To determine the correct infusion rate, first, calculate the total volume to be infused over 4 hours (250 ml). Then, divide the total volume by the total time to get the hourly rate (250 ml / 4 hours = 62.5 ml/hour, rounded to 63 ml/hour). Option A) 13 ml/hour is incorrect because it is too slow and would not deliver the required dose within the specified time frame. Option C) 80 ml/hour and Option D) 125 ml/hour are also incorrect as they would deliver the solution too quickly, potentially causing adverse effects due to a rapid infusion rate. Educationally, this question assesses the nurse's ability to calculate and set the correct intravenous infusion rate based on the prescribed medication dosage and administration parameters. Understanding how to perform these calculations accurately is crucial for nurses to ensure safe and effective medication administration to patients. It also highlights the importance of attention to detail and precision in nursing practice.