Nokea
A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.
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The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.
An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
- A. Septicemia
- B. Dehydration
- C. Hypokalemia
- D. Hypercalcemia
Correct Answer: B
Rationale: Dehydration. These symptoms are consistent with dehydration, requiring further assessment for fluid status.
The nurse has reinforced teaching with a client who has gout. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Drink plenty of fluids, including at least 2 L of water daily
- B. Reduce your consumption of alcohol or abstain from drinking
- C. Take aspirin instead of acetaminophen for minor pain or discomfort
- D. Implement a diet and physical activity regimen to maintain a healthy weight
- E. Select protein sources that are low in purine, such as low-fat dairy products
Correct Answer: A,B,D,E
Rationale: Fluids, reduced alcohol, weight management, and low-purine proteins reduce uric acid and gout flares. Aspirin can increase uric acid levels, worsening gout, and should be avoided.
The nurse is reinforcing information on dietary management to a group of clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?
- A. Baked tilapia with tomato salsa, steamed white rice
- B. Black bean chili with brown rice, mixed greens salad
- C. Grilled chicken breast with baked French fries
- D. Hamburger on a whole wheat bun with lettuce and tomato
Correct Answer: B
Rationale: Baked bean chili with brown rice and salad provides fiber, lean protein, and vegetables, balancing blood sugar. Fries and hamburger buns are higher in simple carbs, less ideal for diabetes control.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.