Nokea
A client receiving filgrastim (Neupogen) for neutropenia is learning about compromised host precautions. The selection of which lunch suggests the client has learned about necessary dietary changes?
- A. grilled chicken sandwich and skim milk
- B. roast beef, mashed potatoes, and green beans
- C. peanut butter sandwich, banana, and iced tea
- D. barbecue beef, baked beans, and cole slaw
Correct Answer: B
Rationale: Roast beef, mashed potatoes, and green beans are suitable choices for clients with neutropenia because they are considered safe options that help avoid potential sources of infection. Grilled chicken, peanut butter, and barbecue beef may carry a higher risk of bacterial contamination, which could be harmful to a client with compromised immunity.
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An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
Correct Answer: B
Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. Abdominal x-ray
- B. Auscultation
- C. Flushing tube with saline
- D. Aspiration for gastric contents
Correct Answer: D
Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.
A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?
- A. Sliced bananas
- B. Raw celery
- C. Peanut butter
- D. Marshmallows
Correct Answer: A
Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.
What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?
- A. Maintain adequate hydration
- B. Assist the client to turn, deep breathe, and cough
- C. Ambulate the client within 12 hours
- D. Splint the incision
Correct Answer: B
Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 g/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct Answer: D
Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.