Nokea
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
- A. High calorie, high protein, high fat
- B. High calorie, high carbohydrate, low protein
- C. High calorie, low carbohydrate, high fat
- D. High calorie, high protein, low fat
Correct Answer: D
Rationale: A high-calorie, high-protein, low-fat diet helps maintain weight and muscle mass in clients with AIDS while minimizing gastrointestinal complications.
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The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
- A. Remove the dressing and replace it with a more absorbent dressing.
- B. Collect a culture and sensitivity specimen of the drainage.
- C. Observe the wound for dehiscence.
- D. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry
The nurse is teaching a client with limited mobility about preventing blood clots. Which statement by the nurse is correct?
- A. Do not cross your legs when sitting.
- B. Avoid riding in a car for more than two hours.
- C. Put a pillow under your knees when lying in bed.
- D. You should ask your doctor to give you a blood thinner.
Correct Answer: A
Rationale: Crossing legs can impede venous return, increasing clot risk, so avoiding this is correct. Long car rides are a risk but not limited to two hours, and pillows under knees can worsen circulation.
A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
- A. I have been helping my family deal with their feelings about the surgery.
- B. I have been having difficulty coping with the surgery and cry frequently.
- C. I have been unable to leave the house or talk to my friends about the surgery.
- D. I am doing just great since the surgery and have gone back to work at my job.
Correct Answer: B
Rationale: normal reaction one month later
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield.
Correct Answer: B
Rationale: Voiding immediately before an IVP ensures the bladder is empty, improving visualization of the urinary tract.
When assessing a client's skin, the nurse notes a scattered red rash on the trunk. The individual lesions are about 0.5 cm in diameter and are flat, nonpalpable, and circumscribed. How would this type of lesion be classified?
- A. Papule
- B. Nodule
- C. Macule
- D. Patch
Correct Answer: C
Rationale: A flat, nonpalpable lesion ≤1 cm is a macule (C). Papules (A) are raised, nodules (B) are deeper and larger, and patches (D) are larger flat lesions.