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A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?
- A. Based on urine output plus 500 mL
- B. 1,000 mL regardless of weight
- C. 20 mL/kg of body weight
- D. Unlimited unless edema is present
Correct Answer: A
Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.
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A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
Select the nurse case management model used for patient care delivery that is accurately paired with one of its descriptors:
- A. The ProACT Model: Registered nurses perform the role of the primary nurse in addition to the related coding and billing functions
- B. The Collaborative Practice Model: The registered nurse performs the role of the primary nurse in addition to the role of the clinical case manager with administrative, supervisory and fiscal responsibilities
- C. The Case Manager Model: The management and coordination of care for clients throughout a facility who share the same DRG or medical diagnosis
- D. The Triad Model of Case Management: The joint collaboration of the social worker, the nursing case manager, and the utilization review team
Correct Answer: D
Rationale: The Triad Model of Case Management accurately describes the collaboration among the social worker, nursing case manager, and utilization review team to coordinate care and optimize outcomes.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.