Nokea
A client must take oral potassium supplements every day. The nurse explains to the client that the potassium supplements
- A. need to be stored in the refrigerator.
- B. should only be taken in the evening before bed.
- C. should be diluted in a glass of cold water or juice.
- D. need to be taken on an empty stomach.
Correct Answer: C
Rationale: Oral potassium supplements should be diluted in water or juice to reduce gastric irritation and improve absorption.
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The nurse is assessing a client with suspected diverticulitis. Which of the following findings would the nurse expect?
- A. Pain in the right upper quadrant.
- B. Fever and left lower quadrant pain.
- C. Diarrhea with bright red blood.
- D. Soft, non-tender abdomen.
Correct Answer: B
Rationale: fever and left lower quadrant pain are common in diverticulitis due to inflammation in the sigmoid colon
If a client is to have a nasogastric (NG) tube inserted for intermittent feedings, which of the following is an appropriate task to delegate to unlicensed assistive personnel?
- A. Inserting the NG tube
- B. Verifying tube position
- C. Administer tube feedings
- D. Reposition a displaced NG tube
Correct Answer: C
Rationale: Administering tube feedings (C) can be delegated to unlicensed assistive personnel if trained, per facility policy. Inserting (A), verifying (B), and repositioning (D) require nursing judgment.
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
- A. Application of a short inclusive spica cast
- B. Stabilization with a plaster-of-Paris cast
- C. Surgery with Kirschner wire implantation
- D. A gauze dressing only
Correct Answer: B
Rationale: A plaster-of-Paris cast is typically used to stabilize foot fractures, ensuring proper alignment and healing.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.