Nokea
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, dairy and meat products cannot be consumed together. The mixing of meat and dairy violates the dietary laws of Kashrut. Kosher chicken breast and boiled potatoes (choice D) are both permissible to eat together as they are both meat products. Carrot sticks and cottage cheese (choice B) are both dairy products and can be consumed together. Macaroni and cheese (choice C) is a dairy product and can be consumed alone or with other dairy products.
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A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?
- A. Initiate protective isolation.
- B. Allow the wound to air periodically.
- C. Clean the incision with soap and water.
- D. Perform hand hygiene prior to dressing changes.
Correct Answer: D
Rationale: The correct answer is D: Perform hand hygiene prior to dressing changes. This is important to prevent introducing harmful bacteria to the surgical wound, reducing the risk of infection. Hand hygiene is a crucial infection control measure as it helps to minimize the transfer of microorganisms. Initiating protective isolation (A) is not necessary for preventing incisional infections. Allowing the wound to air periodically (B) can actually increase the risk of contamination. Cleaning the incision with soap and water (C) may not be appropriate as it can irritate the wound and disrupt the healing process.
A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
- A. Keep a night light on in the client's room and bathroom.
- B. Keep the bed at a comfortable working height.
- C. Lock the wheels on beds and wheelchairs during transfers.
- D. Place the bedside table within the client's reach.
- E. Administer a sedative at bedtime.
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items. Choice B is incorrect as bed height doesn't directly impact fall risk. Choice E, administering a sedative, can increase fall risk due to drowsiness.
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?
- A. Determine the client's perception of his body image.
- B. Encourage the client to talk about his feelings regarding his body image.
- C. Discuss alternative coping strategies to relieve stress he feels about his body image.
- D. Assist the client to acknowledge he has a distorted body image.
Correct Answer: A
Rationale: Assessing the client's perception of their body image is the first step in understanding their emotional and psychological response.