Nokea
A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to
- A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
- B. Ask the client what foods are acceptable or are unacceptable
- C. Encourage her to eat for healing and strength
- D. Schedule the dietitian to meet with the client as soon as possible
Correct Answer: B
Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.
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A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders?
- A. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
- B. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
- C. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease.
- D. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained bradycardia below 30.
Correct Answer: A
Rationale: Lidocaine suppresses ventricular activity, which could worsen complete heart block by reducing the ventricular escape rhythm. Options B, C, and D are appropriate: atropine increases heart rate, pacemakers treat persistent bradycardia, and isoproterenol supports severe bradycardia.
Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
- A. Sodium
- B. Potassium
- C. Chloride
- D. Magnesium
Correct Answer: A
Rationale: Sodium levels must be stable in clients taking lithium, as fluctuations can affect lithium levels and toxicity risk.
The nurse is caring for a client with chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results should the nurse report immediately?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high, risking hypertension or thrombosis with epoetin alfa. Options B, C, and D are expected or normal.
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple association of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originate from their own perspective
- D. Conclusions are based on previous experiences
Correct Answer: B
Rationale: They are able to think logically in organizing facts. The child in the concrete operations stage is capable of mature thought when organizing objects.