Nokea
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
- A. What is the best indication that the nutritional status of a woman with metastatic ovarian cancer has improved after 4 days of TPN?
- B. The patient eats most of the food served to her.
- C. The patient has gained 1 pound since admission.
- D. The patient’s albumin level is 0 mg/dL.
- E. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.
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A 14-year-old is going home with a permanent tracheostomy. Which comment by the child's mother indicates to the nurse that the parent needs more instruction?
- A. I need to ask the doctor how many times a day I can suction my child.'
- B. I will suction if my child cannot effectively cough up sputum.'
- C. I know my child will not need the same amount of suctioning every day.'
- D. I know I should only suction my child if it is really necessary.'
Correct Answer: A
Rationale: Asking for a fixed suctioning schedule suggests misunderstanding, as suctioning is PRN based on need, indicating a need for further instruction.
A client with paralysis from a cerebrovascular accident (CVA).
Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?
- A. Maintain adduction of the affected shoulder.
- B. Prevent flexion of the affected extremities.
- C. Observe active range of motion (ROM) daily to all extremities.
- D. Maintain external rotation of the affected hip.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct-flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client's plate
- D. Providing the client with child-sized utensils
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.
A client administering his own insulin.
Which observation indicates to the nurse that the client needs further teaching before he can administer his own insulin?
- A. The client draws up his regular insulin first, then the NPH.
- B. The client gently rotates the insulin bottle before withdrawing the dose.
- C. The client rotates injection sites following the guide on his printed diagram.
- D. The client administers the insulin while it is still cold from the refrigerator.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH) (2) bottle of insulin should never be vigorously shaken, but rather gently mixed (3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption (4) correct-insulin should be administered at room temperature, temperature extremes should be avoided