Nokea
A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?
- A. Check the protein level in urine
- B. Have the client turn to the left side
- C. Take the temperature
- D. Monitor the urine output
Correct Answer: B
Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.
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A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?
- A. Eating yogurt can help decrease gas odor that I have.
- B. I should eliminate pasta from my diet so that I don't have as many loose stools.
- C. My largest meal of the day should be in the evening.
- D. Carbonated beverages can help control odor.
Correct Answer: A
Rationale: The correct answer is A. Yogurt contains probiotics which can help reduce gas and odor in colostomy patients. Choice B is incorrect because pasta is a low-fiber food that can help thicken stools, which may be beneficial for colostomy patients. Choice C is incorrect because it is generally recommended for colostomy patients to have their largest meal earlier in the day to allow for better digestion. Choice D is incorrect because carbonated beverages can actually increase gas production and worsen odor in colostomy patients.
A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?
- A. Sliced bananas
- B. Raw celery
- C. Peanut butter
- D. Marshmallows
Correct Answer: A
Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.
A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct Answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.
What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?
- A. Maintain adequate hydration
- B. Assist the client to turn, deep breathe, and cough
- C. Ambulate the client within 12 hours
- D. Splint the incision
Correct Answer: B
Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.
The client is preparing for a myelogram. Which of the following statements by the client indicates a contraindication for this test?
- A. I can't lie in one position for more than thirty minutes.
- B. I am allergic to shrimp.
- C. I suffer from claustrophobia.
- D. I developed a severe headache after a spinal tap.
Correct Answer: B
Rationale: An allergy to shrimp is a contraindication for a myelogram because the contrast dye used in the procedure contains iodine, which can trigger allergic reactions in individuals allergic to shellfish. Choices A, C, and D are not contraindications for a myelogram. Inability to lie still for an extended period, claustrophobia, or a previous headache after a spinal tap are concerns that can be managed during the procedure but do not necessarily prevent the test from being performed.