Nokea
A low-purine diet is ordered for a client who has uric acid kidney stones. Which foods should the client avoid? Select all that apply.
- A. Eggs
- B. Chicken
- C. Liver
- D. Oats
- E. Lentils
- F. Lobster
Correct Answer: C,F
Rationale: Liver and lobster are high-purine foods, increasing uric acid production, which worsens uric acid kidney stones. Eggs, chicken, oats, and lentils are lower in purines and safer.
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The nurse is caring for a client with a history of meningitis.
- A. Which precaution is most appropriate for a client with bacterial meningitis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: B
Rationale: Droplet precautions are required for bacterial meningitis (e.g., Neisseria meningitidis) to prevent transmission via respiratory secretions. Standard precautions are insufficient, and contact or airborne precautions are incorrect.
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
- A. Slow the infusion and monitor the blood pressure.
- B. Check the client for signs of infection.
- C. Discontinue the medication and document the action.
- D. Continue the infusion because this is a normal reaction.
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.
The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct Answer: A
Rationale: High Fowler's. This position decreases cardiac workload and facilitates breathing.
The nurse is caring for a client with a history of falls.
- A. Which intervention should be included in the care plan for a client with a history of falls?
- B. Keep the bed in a high position to discourage getting out of bed.
- C. Encourage the client to remain in bed as much as possible.
- D. Place a night light in the bathroom.
- E. Restrict the client’s fluid intake in the evening.
Correct Answer: C
Rationale: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.