Nokea
A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?
- A. Macaroni and cheese
- B. One medium apple with skin
- C. One cup of plain yogurt
- D. Roast chicken and white rice
Correct Answer: B
Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.
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A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:
- A. Administer cardiac compressions
- B. Attach the AED pads to the client
- C. Check for a pulse
- D. Perform rescue breaths
Correct Answer: A
Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.
The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?
- A. The injury is expected to heal quickly because of thin periosteum.
- B. In some instances the result is a retarded bone growth.
- C. Bone growth is stimulated in the affected leg.
- D. This type of injury shows more rapid union than that of younger children.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare professional is caring for a client with a chest tube. What is the most important action for the healthcare professional to take to ensure the chest tube is functioning properly?
- A. Milk the chest tube to ensure patency.
- B. Clamp the chest tube when moving the client.
- C. Ensure the water seal chamber is filled to the appropriate level.
- D. Secure the chest tube to the client's bed.
Correct Answer: C
Rationale: Ensuring the water seal chamber is filled to the appropriate level is crucial to maintain the effectiveness of the chest tube drainage system. This step helps prevent air from entering the pleural space, ensuring proper lung re-expansion. 'Milking' the chest tube is not recommended as it can cause damage to the chest tube and surrounding tissues. Clamping the chest tube is not advisable as it can lead to tension pneumothorax. Securing the chest tube to the bed is important for stability but does not directly impact the functioning of the chest tube.
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled 1.5 grains per tablet. How many tablets should the LPN/LVN plan to administer?
- A. 0.5 tablet
- B. 1 tablet
- C. 1.5 tablets
- D. 2 tablets
Correct Answer: B
Rationale: To calculate the number of tablets needed, convert the prescribed dose of Seconal from grams to grains. Since 1 gram is equal to approximately 15.43 grains, 0.1 gram is roughly 1.543 grains. Given that each tablet contains 1.5 grains, administering 1 tablet (which is slightly more than the 1.543 grains needed) provides the correct dose of Seconal. Therefore, the LPN/LVN should plan to administer 1 tablet. Choice A (0.5 tablet) is incorrect as it would provide less than the required dose. Choice C (1.5 tablets) and Choice D (2 tablets) are incorrect as they would exceed the necessary dosage.
UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?
- A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
- B. The urine meter attached to the urinary drainage bag is completely full.
- C. There is a large dependent loop in the client's urinary drainage tubing.
- D. Purulent drainage is present around the insertion site of the feeding tube.
Correct Answer: D
Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.