Nokea
A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select one that doesn't apply).
- A. Cottage cheese
- B. Milkshake
- C. Tuna fish
- D. Strawberries and bananas
Correct Answer: D
Rationale: The correct answer is D - Strawberries and bananas. Cottage cheese, milkshakes, and tuna fish are high in protein and calories, making them beneficial in preventing protein-energy malnutrition. However, strawberries and bananas are not as protein or calorie-dense compared to the other options, so they are not as effective in preventing malnutrition.
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The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.
A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?
- A. I will drink water with my meals.
- B. I will eat every 6 hours throughout the day.
- C. I will eat crackers before I get out of bed in the morning.
- D. I will limit my protein intake.
Correct Answer: C
Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.
After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.
When speaking with a group of teens, which side effect of chemotherapy for cancer would the nurse expect this group to be more interested in discussing?
- A. Mouth sores
- B. Fatigue
- C. Diarrhea
- D. Hair loss
Correct Answer: D
Rationale: Hair loss is the correct answer. Teens are often more concerned about hair loss because of its visible impact and social implications. While mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, hair loss tends to be a significant concern for teens due to its effect on self-image and confidence.
During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?
- A. S3 ventricular gallop
- B. Apical click
- C. Systolic murmur
- D. Split S2
Correct Answer: A
Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.