Nokea
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.
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A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
A nurse is assisting an older adult client plan an exercise regimen. Which of the following activities should the nurse encourage the client to avoid?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Older adults may have joint issues, reduced bone density, or balance problems which could be exacerbated by the high impact nature of running. Encouraging the client to avoid running can help prevent injuries. Stretching (A) helps maintain flexibility, resistance training (C) improves strength, and aerobic exercises (D) enhance cardiovascular health, all of which are beneficial for older adults.
A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.
A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?
- A. Corticosteroids
- B. NSAIDs
- C. ACE inhibitors
- D. SSRIs
Correct Answer: A
Rationale: Corticosteroids can cause potassium loss through increased renal excretion, leading to hypokalemia.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.