Nokea
A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water each day
- D. Drink hot water with lemon juice each morning
Correct Answer: D
Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.
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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. Client with surgical hypoparathyroidism and positive Trousseau's sign
- B. Client with Clostridium difficile and acute diarrhea
- C. Client with acute kidney injury and low urine specific gravity
- D. Client with oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.
A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?
- A. I steal things because it's the only way I can keep my mind off my bad marriage
- B. I can't believe I was accused of something I didn't do
- C. I don't want to talk about my feelings right now; we will talk more next time
- D. I think that people should earn money honestly, even though I stole
Correct Answer: D
Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.
A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?
- A. Fasting blood glucose
- B. Carbohydrate intake
- C. Hematocrit
- D. Weight
Correct Answer: D
Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.
A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?
- A. Adjust the flow rate of the client's oxygen tank
- B. Collect a urine sample
- C. Measure the client's pain level
- D. Monitor blood glucose levels
Correct Answer: B
Rationale: The correct answer is B: Collect a urine sample. Delegating this task to assistive personnel is appropriate as it falls within their scope of practice. Tasks like adjusting the flow rate of oxygen tanks, measuring pain levels, and monitoring blood glucose levels require clinical judgment and should be performed by a nurse. It is important for nurses to delegate tasks that align with the competencies of assistive personnel to ensure safe and effective patient care.
A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct Answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.