Nokea
A client in hospice care is nearing death. Which of the following is an expected physical change the nurse should prepare the family for?
- A. Increased appetite.
- B. Cool, mottled extremities.
- C. Improved mental clarity.
- D. Regular breathing patterns.
Correct Answer: B
Rationale: Cool, mottled extremities are an expected sign of impending death due to decreased circulation, and preparing the family helps reduce distress.
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Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply.
- A. Bran cereal.
- B. Broccoli.
- C. Tomato juice.
- D. Navy beans.
- E. Cheese.
Correct Answer: A,B,D
Rationale: Bran cereal (A), broccoli (B), and navy beans (D) are high-fiber foods that help prevent complications in diverticulosis by promoting regular bowel movements. Tomato juice (C) and cheese (E) are not high in fiber. CN: Physiological adaptation; CL: Create
A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2°C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider:
- A. Continues the pentoxifylline
- B. Increases the I.V. fluids
- C. Restarts the metoprolol
- D. Resumes the furosemide
Correct Answer: C
Rationale: SBAR: Situation€”postop day 1, heart rate 132 bpm. Background€”aortobifemoral bypass, history of hypertension, on metoprolol preop. Assessment€”tachycardia suggests inadequate beta-blockade, other vitals stable. Recommendation€”restart metoprolol to control heart rate and blood pressure. Pentoxifylline is less urgent, fluids are adequate (urine output normal), and furosemide may cause dehydration.
The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. This observation should prompt the nurse to do which of the following?
- A. Continue monitoring as usual; this is expected.
- B. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle.
- C. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours.
- D. Drain half of the water from the water-seal chamber.
Correct Answer: B
Rationale: Constant gentle bubbling in the water-seal column suggests an air leak; checking connectors identifies the source. Expected bubbling is intermittent. Adjusting suction or draining water is inappropriate.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
- A. A Bible.
- B. A picture.
- C. A sachet of lavender.
- D. A hairbrush.
Correct Answer: C
Rationale: During leukemia induction therapy, the client is immunocompromised, and scented items like a lavender sachet may harbor bacteria or cause allergic reactions. A Bible, picture, and hairbrush (if clean) are safe and support emotional well-being.