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The school nurse is monitoring the diet of a child with celiac disease. What lunch menu item would the nurse recommend to the family?
- A. ham and cheese sandwich
- B. chef salad with oil and vinegar dressing
- C. chili with corn bread
- D. vegetarian pizza with lactose-free cheese
Correct Answer: B
Rationale: A chef salad with oil and vinegar is gluten-free, suitable for celiac disease. The other options contain gluten.
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A newly graduated nurse has been assigned a client who has a chest tube following a thoracotomy. The new nurse is not experienced with chest tube management. Which action by the nurse is most appropriate regarding this assignment?
- A. ask for a different group of clients
- B. ask to be floated to another area in the facility
- C. refuse the assignment, since she is not familiar with chest tubes
- D. accept the assignment and ask for another nurse to help her with the chest tube
Correct Answer: D
Rationale: Accepting the assignment and seeking help ensures client care while addressing the nurse's inexperience safely.
A nurse assigned to a client with congestive heart failure (CHF) is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.
- A. The nurse should reduce fluid intake to less than 1,000 ml per shift.
- B. The nurse should keep the client in a supine position as much as possible.
- C. The nurse should encourage alternating activity with rest periods.
- D. The nurse should assess the ankles, legs, and feet for pitting edema.
Correct Answer: C,D
Rationale: Encouraging activity with rest and assessing for edema are appropriate for CHF management. Fluid restriction is typically 1,500-2,000 ml/day, and supine positioning may worsen breathing.
The nurse is working with a newly hired unlicensed assistive personnel (UAP). Several activities of daily living need to be completed for the nurse's clients. Which task should the nurse delegate to the UAP?
- A. performing oral care on a client with a bleeding disorder
- B. turning a client with a tibial fracture with external fixation
- C. assisting a client admitted with COPD exacerbation to the chair
- D. reinforcing teaching on use of the inhaler for a client with asthma
Correct Answer: C
Rationale: Assisting a stable COPD client to the chair is within the UAP's scope. The other tasks require nursing judgment or skill.