A client diagnosed with stable angina is being discharged ho...

The nurse knows that the mother understands the dietary instructions for her toddler who has iron deficiency anemia when the mother selects which foods?

A. Whole milk, carrots, and chicken pieces
B. Ground beef, broccoli, and orange juice
C. Liver, lima beans, and skim milk
D. Macaroni and cheese, peas, and cola

Correct Answer: B

Rationale: Ground beef and broccoli are iron-rich, and orange juice (vitamin C) enhances iron absorption, ideal for iron deficiency anemia. Milk-heavy diets can inhibit iron absorption.

The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.

A. Dress the infant in warm clothing and blankets
B. Encourage smaller, frequent feedings
C. Intervene quickly to prevent the infant from crying excessively
D. Promote a quiet period on waking in the morning
E. Turn the infant frequently during sleep

Correct Answer: B,C,D

Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.

Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)

Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)

Female: 12-16 g/dL
(120-160 g/L)

The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?

A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty

Correct Answer: A

Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.

The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.

A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
B. Increase your consumption of iron-rich foods like meat and dried fruit
C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation

Correct Answer: A,B,D,E

Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.

A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.

A. Administer 1 oral tablet of oxycodone prescribed PRN for pain
B. Collect a full set of vital signs
C. Cover the viscera with sterile dressings saturated in normal saline solution
D. Notify the health care provider immediately
E. Place the client in the low Fowler position with knees slightly flexed

Correct Answer: B,C,D,E

Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.

NCLEX PN Practice Tests Related

Correct Answer: D