Nokea
A nurse is assisting a client in selecting an appropriate diet. Which of the following statements should the nurse make?
- A. Choose foods high in fiber and low in fat.
- B. Include a variety of fruits and vegetables.
- C. Drink plenty of water throughout the day.
- D. Limit the intake of sugary and processed foods.
Correct Answer: A
Rationale: High-fiber, low-fat foods support digestion and heart health.
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A nurse is assisting with the care of a male client in the unit. Complete the following sentence by using the list of options. The client is at risk for developing ___ due to ___.
- A. Aspiration pneumonia
- B. Coughing when eating
- C. sweating
- D. increased heart beat
Correct Answer: A,B
Rationale: A: Coughing during eating increases aspiration risk. B: Indicates potential airway entry.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?
Correct Answer: 660 mL
Rationale: 8 oz milk (240 mL) + 10 oz water (300 mL) + 4 oz gelatin (120 mL) = 660 mL; only liquids are recorded.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.
A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?
- A. Verify the bilirubin level of the tube contents.
- B. Check the pH level of gastric contents.
- C. Auscultate for air insufflation.
- D. Request a chest x-ray.
Correct Answer: D
Rationale: A chest x-ray visually confirms tube placement, the most reliable method.