Nokea
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
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The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .
A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct Answer: D
Rationale: The infant received mechanical ventilation for 2 weeks. Bronchopulmonary dysplasia is often caused by prolonged mechanical ventilation.
The nurse is caring for a client with a history of stroke.
- A. Which intervention is most effective for preventing aspiration in a client with a history of stroke?
- B. Thicken liquids to a nectar consistency.
- C. Encourage small, frequent meals.
- D. Place the client in a supine position for meals.
- E. Administer an antiemetic before meals.
Correct Answer: A
Rationale: Thickening liquids to a nectar consistency slows swallowing, reducing aspiration risk in stroke patients with dysphagia. Small meals help, supine positioning increases risk, and antiemetics are irrelevant.
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast.
- A. What should the nurse do first for a six-year-old complaining of pain in his left foot several hours after hip spica cast application?
- B. Elevate the left leg on two pillows.
- C. Palpate the cast for warmth and wetness.
- D. Administer pain medication as ordered.
- E. Check the blanching sign on both feet.
Correct Answer: D
Rationale: Pain in the foot post-cast application suggests possible circulatory impairment. Checking the blanching sign (capillary refill) assesses circulation, comparing the affected and unaffected sides. Elevation, palpation, or medication may follow but do not address the urgent need to assess circulation.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.