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A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse advise the client to avoid?
- A. Apples.
- B. Bananas.
- C. Cauliflower.
- D. White bread.
Correct Answer: B
Rationale: Bananas are high in potassium, which must be limited in chronic kidney disease to prevent hyperkalemia.
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The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
- A. Anticipate lesions within 25 to 30 days.
- B. Continue sexual activity unless lesions are present.
- C. Report any difficulty urinating.
- D. Drink extra fluids to prevent lesions from forming.
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
- A. Provide the client with oral hygiene.
- B. Offer the client liquids to drink.
- C. Encourage the client to cough and deep breathe.
- D. Auscultate the client's bowel sounds.
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
- A. The nurse must know the nursing model that underlies care at the institution.
- B. The nurse delegates in accordance with demands on his/her time.
- C. The nurse validates with the non-RN caregiver that he/she has performed the same activity before.
- D. The nurse retains the right to determine which tasks are delegated.
- E. The nurse must account that the task has been delegated and to whom.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.