Nokea
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
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The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
- A. Increase fluid intake to prevent dehydration
- B. Place client on a pressure reducing support surface
- C. Use skin care products designed for use with incontinence
- D. Increase caloric intake to aid healing
Correct Answer: B
Rationale: Place client on a pressure reducing support surface. This prevents skin breakdown due to immobility and reduced sensation.
The client is scheduled for a myelogram today. The permit has been signed. The client tells the nurse that she has changed her mind and does not want to have the procedure. What should the nurse do?
- A. Tell the client that once permission has been given, the procedure has to be done
- B. Tell the client that the physician will be very upset if she does not have it done
- C. Suggest to the client that it is in her best interests to have the procedure as scheduled
- D. Understand that the client has the right to change her mind about procedures
Correct Answer: D
Rationale: Clients have the right to withdraw consent at any time, respecting autonomy. Coercion or suggesting physician displeasure is unethical.
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
- A. Rotation of injection sites
- B. Insulin mixing and preparation
- C. Daily blood sugar monitoring
- D. Regular high protein diet
Correct Answer: C
Rationale: Daily blood sugar monitoring. Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation