A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice enhances iron absorption in iron-deficiency anemia via vitamin C, reducing ferric to ferrous form for better uptake a proven dietary aid. Milk inhibits it, water or apple juice lack this boost. Nurses teach this pairing, improving hemoglobin levels, optimizing therapy for fatigue and pallor relief.
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How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
- A. Draw up the NPH insulin, then the regular insulin, in the same syringe
- B. Draw up the regular insulin, then the NPH insulin, in the same syringe
- C. Use two separate syringes
- D. Check with the physician
Correct Answer: B
Rationale: Regular (clear) is drawn first, then NPH (cloudy), to avoid contamination.
Anaphylactic reaction after administering penicillin indicates
- A. An acquired atopic sensitization
- B. Passive immunity to penicillin allergen
- C. Antibodies to penicillin developed after earlier use of the drug
- D. Developed potent bivalent antibodies when the IV administration was started
Correct Answer: C
Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.
The nurse working in the community is assigned to the care of several clients. Which client(s) may require assistance to overcome barriers to accessing adequate care?
- A. A student entering a local university
- B. A client who is a migrant and works on a farm
- C. An older adult client living independently
- D. A client who has been unemployed for 6 months
Correct Answer: B
Rationale: Barriers to healthcare access often hit vulnerable groups hardest, requiring nursing intervention. A migrant farm worker faces language, mobility, and economic hurdles, limiting care access e.g., no insurance or transport. An older adult living alone may struggle with mobility, health literacy, or isolation, delaying treatment. An unemployed client, lacking income or coverage, often skips care due to cost, risking worsening conditions. A student entering university or an employed pregnant client typically has fewer systemic barriers students may access campus health, employed clients insurance. Nursing must target the migrant, elderly, and jobless, addressing disparities poverty, age, ethnicity ensuring equitable care. This reflects nursing's equity mission, bridging gaps for those society sidelines, enhancing health outcomes through advocacy and resource linkage.
All of the following can cause tachycardia except:
- A. Fever
- B. Exercise
- C. Sympathetic nervous system stimulation
- D. Parasympathetic nervous system stimulation
Correct Answer: D
Rationale: Parasympathetic stimulation slows heart rate; others increase it.
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.