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A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?
- A. I would like to see what this looks like today.
- B. I would just like to spend my day staring at the TV.
- C. I'm going to close my eyes until you are done dressing my incision.
- D. I'm planning to stay at home until my breast reconstructive surgery.
- E. I don't care about my appearance anymore.
- F. I'll never leave the house again.
- G. I feel fine and don't need help.
Correct Answer: A
Rationale: Wanting to see the incision shows acceptance and engagement in recovery; other options suggest avoidance or denial.
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A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Request a dosage increase if the apical heart rate is less than 60/min.
- B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- C. Administer the medication with an antacid.
- D. Instruct the client to expect increased hair growth.
Correct Answer: B
Rationale: Propranolol is a beta-blocker, and it should be withheld if the systolic blood pressure is below 90 mm Hg to prevent hypotension. A heart rate below 60/min might also warrant withholding, not increasing, the dose, and the other options are unrelated to its administration.
A nurse is contributing to the plan of care for a client who is postoperative following a fasciotomy. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Assist the client to the restroom 30 min after meals.
- C. Offer small, frequent meals.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: C
Rationale: Post-fasciotomy care focuses on pain management, wound healing, and monitoring for complications like infection or compartment syndrome recurrence, not dietary or reproductive restrictions. Offering small, frequent meals supports nutritional needs without overloading the stomach, aiding recovery by maintaining energy for tissue repair, especially if appetite is reduced from pain or medications. A pureed diet is unnecessary unless swallowing is impaired, which isn't indicated here fasciotomy addresses limb pressure, not GI issues. Assisting to the restroom post-meals relates to bowel training, irrelevant to this surgical context. Avoiding sexual intercourse applies to pelvic procedures like colposcopy, not a limb fasciotomy. Small, frequent meals align with postoperative principles, promoting healing and comfort, making it the most relevant intervention for this client's plan of care, enhancing overall recovery without complicating the surgical focus.
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
- A. Pull the fire alarm panel.
- B. Obtain a fire extinguisher.
- C. Remove the client from the room.
- D. Close the door to the client's room.
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.
A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?
- A. 240 mL (8 oz) tomato juice
- B. 240 mL (8 oz) low-fat strawberry Greek yogurt
- C. 1 cup cooked peas
- D. 1 medium banana
Correct Answer: C
Rationale: Fiber content varies widely among foods, and cooked peas top this list. One cup of cooked peas offers about 8-9 grams of fiber, thanks to their legume properties, promoting bowel health and satiety. Tomato juice (8 oz) has roughly 1-2 grams mostly water, low in bulk. Low-fat strawberry Greek yogurt provides minimal fiber (<1 gram), as dairy lacks it naturally, despite added fruit. A medium banana has about 3 grams, decent but far below peas. Recommending peas educates the client on a nutrient-dense, high-fiber choice, aligning with dietary guidelines (e.g., 25-30 grams daily), supporting digestion, and preventing chronic diseases like diverticulosis, making it the best option to highlight.
A nurse in a provider's office is assisting in the care of a client. For each potential provider's prescription, which is anticipated for the client?
- A. Administer an iron supplement.
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Given the client's vegan diet, fatigue, weakness, pale mucous membranes, and rapid pulse (Exhibit 1), iron deficiency anemia is likely. Administering an iron supplement is anticipated it corrects low hemoglobin, a common vegan shortfall without meat or fortified sources, directly addressing the suspected etiology. Nutritional consultation helps long-term, but immediate supplementation is urgent for symptom relief and oxygen delivery. A low-sodium diet suits heart failure or hypertension, not anemia blood pressure (132/60 to 102/50 mm Hg) reflects orthostasis, not sodium issues. Fluid restriction applies to fluid overload, not here, where hydration supports circulation. Iron supplementation aligns with anemia management guidelines (e.g., ferrous sulfate), offering rapid hematologic improvement, making it the expected prescription for this presentation.