Nokea
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
- A. Protect the child from infection
- B. Provide the child with privacy
- C. Protect the family from curious visitors
- D. Isolate the child from other clients and the nursing staff
Correct Answer: A
Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.
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The nurse is teaching a client with a history of osteoporosis about dietary modifications. The nurse should tell the client to increase intake of:
- A. Calcium-rich foods
- B. High-fiber foods
- C. Low-fat foods
- D. High-protein foods
Correct Answer: A
Rationale: Calcium-rich foods strengthen bones and help prevent further bone loss in osteoporosis, a critical dietary modification.
The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client?
- A. Tell the client to avoid stairs
- B. Tell the client to decrease her intake of sodium
- C. Instruct the client to weigh daily
- D. Tell the client to report numbness and tingling in her feet and toes
Correct Answer: D
Rationale: Numbness and tingling in the feet and toes may indicate diabetic neuropathy a serious complication requiring prompt reporting. Avoiding stairs reducing sodium or daily weighing are not specific to diabetes management unless indicated.
Which measure helps reduce nipple soreness associated with breastfeeding?
- A. Feeding the baby during the first 48 hours after delivery
- B. Placing a finger between the baby's mouth and the breast to break suction after feeding
- C. Applying warm, moist soaks to the breast several times per day
- D. Wearing a support bra during the day
Correct Answer: B
Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.
The nurse is teaching a client with a history of chronic sinusitis about self-care. The nurse should tell the client to:
- A. Use a humidifier
- B. Avoid hydration
- C. Use decongestants excessively
- D. Sleep with the head lowered
Correct Answer: A
Rationale: A humidifier keeps nasal passages moist, reducing irritation and promoting drainage in chronic sinusitis.
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.