Nokea
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a common complication of vomiting due to significant fluid loss.
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A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?
- A. Ground beef
- B. Raw vegetables
- C. Fruit with the skin
- D. High-fiber cereals
Correct Answer: A
Rationale: Ground beef is soft and easy to chew, suitable for a soft diet.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
- A. Assist the client to low Fowler's position.
- B. Test the pH of gastric aspirate.
- C. Discard any residual gastric contents.
- D. Warm the feeding solution to body temperature.
Correct Answer: B
Rationale: Testing gastric aspirate pH confirms NG tube placement in the stomach (pH 1-4).
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.