Nokea
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
- A. Angel food cake.
- B. Banana.
- C. Dried fruit.
- D. Orange juice.
- E. Peppers.
Correct Answer: B,C,D
Rationale: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
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The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes:
- A. Bradycardia.
- B. Complete muscle relaxation.
- C. Hypotension.
- D. Tachypnea.
Correct Answer: C
Rationale: Thiopental can cause hypotension, which is particularly risky in clients with impaired cardiac function, as it may exacerbate cardiovascular instability during induction.
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
- A. There is no odor from the stoma.
- B. The client is adequately hydrated.
- C. There is no skin irritation around the stoma.
- D. The client only changes the ostomy pouch once a day.
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels in hepatic encephalopathy. Coordination (C) and pupil reaction (D) are less relevant. High carbohydrates (E) are not specific, and physical activity (F) may be limited.
A client is to have a Schilling test. The nurse should:
- A. Administer methylcellulose (Citrucel).
- B. Start a 24- to 48-hour urine specimen collection.
- C. Maintain nothing-by-mouth (NPO) status.
- D. Start a 72-hour stool specimen collection.
Correct Answer: B
Rationale: The Schilling test assesses vitamin B12 absorption by measuring urinary excretion of radiolabeled B12. The nurse should start a 24- to 48-hour urine collection to capture the excreted B12. Methylcellulose, NPO status, and stool collection are not part of the Schilling test protocol.