Nokea
A client with osteoporosis is being taught about dietary management. Which statement indicates an understanding of the teaching?
- A. I should increase my intake of foods high in vitamin D.
- B. I should decrease my intake of foods high in calcium.
- C. I should increase my intake of foods high in phosphorus.
- D. I should decrease my intake of foods high in potassium.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of foods high in vitamin D is beneficial for improving calcium absorption and managing osteoporosis. Vitamin D helps the body absorb calcium, which is essential for bone health and can aid in managing osteoporosis effectively. Choice B is incorrect because reducing calcium intake would be counterproductive for a client with osteoporosis, as calcium is crucial for bone strength. Choice C is incorrect as phosphorus, while important for bone health, does not directly impact osteoporosis management as much as vitamin D and calcium. Choice D is incorrect as potassium is not directly linked to osteoporosis management, and reducing its intake is not typically part of dietary recommendations for osteoporosis.
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The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?
- A. Stridor
- B. Lung congestion
- C. Occasional pink-tinged sputum
- D. Respiratory rate of 26 breaths per minute
Correct Answer: A
Rationale: Post-extubation after radical neck dissection, stridor (A) indicates airway obstruction (e.g., edema, laryngospasm), requiring immediate RN reporting. Lung congestion (B) or pink sputum (C) suggest fluid but are less urgent. A rate of 26 (D) is elevated but not critical alone. A is correct. Rationale: Stridor signals potential airway compromise, a life-threatening emergency post-neck surgery due to swelling or structural changes, necessitating rapid intervention like reintubation or steroids, per post-operative care standards, unlike less acute findings.
A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?
- A. Avoid foods high in potassium.
- B. Monitor weight daily.
- C. Take the medication with food.
- D. Increase salt intake.
Correct Answer: B
Rationale: Monitoring weight daily is crucial when taking furosemide to detect fluid retention or loss. Furosemide is a diuretic that helps the body get rid of excess water and salt through urine. Changes in weight can indicate fluid shifts, which could be a sign of inadequate response to the medication or worsening condition. Therefore, monitoring weight daily is essential to assess the effectiveness of furosemide therapy and detect any potential issues early on. Choices A, C, and D are incorrect. Avoiding foods high in potassium is more relevant for clients taking potassium-sparing diuretics, not furosemide. Taking furosemide with food is not necessary, as it can be taken with or without food. Increasing salt intake is contradictory to the purpose of furosemide, which aims to eliminate excess salt from the body.
Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is
- A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
- B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
- C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
- D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium
Correct Answer: A
Rationale: The wet-to-dry dressing method (A) is a mechanical debridement technique where a wet gauze is applied to a wound, then dries, adhering to and removing necrotic tissue when peeled off. Surgical debridement (B) involves cutting, not dressings. Option C misrepresents it as a protective dressing, ignoring debridement. Option D describes wet-to-moist dressings, not wet-to-dry. Wet-to-dry targets dead tissue removal, aiding healing in wounds like Imelda's, making A accurate and the best response.
Common clinical feature of renal carcinoma is:
- A. Dysuria
- B. Pain less haematuria
- C. Urgency
- D. Erythema
Correct Answer: B
Rationale: Renal carcinoma (e.g., renal cell carcinoma) often presents insidiously. Dysuria (choice A) suggests infection, not cancer. Painless hematuria (choice B) is classic, as tumors bleed into urine without early pain, often the first sign. Urgency (choice C) relates to bladder issues, not renal tumors. Erythema (choice D) is skin redness, unrelated. B is correct, reflecting renal carcinoma's hallmark. Nurses educate on reporting hematuria, monitor for flank pain or mass (later signs), and support diagnostic imaging, aiding early detection.
In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?
- A. A Glasgow Coma Scale score of 13
- B. Clear fluid leaking from the nose
- C. Nausea and vomiting
- D. Anisocoria
Correct Answer: B
Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.