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A nurse is caring for a client with a chronic wound. Which of the following is a potential complication of a chronic wound?
- A. Electrolyte abnormalities
- B. Altered hemoglobin ATC
- C. Psychological distress
- D. Fluid volume overload
Correct Answer: C
Rationale: Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities. Electrolyte abnormalities are not typically a direct complication unless associated with severe infections or extensive fluid loss, which is uncommon. The wound itself does not directly alter hemoglobin A1C, which measures long-term blood glucose control. Fluid volume overload is not a direct complication of chronic wounds.
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A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
- A. 1 cup canned black beans
- B. 8 a whole milk
- C. 1.5 oz raisins
- D. 8 or black tea
Correct Answer: A
Rationale: Black beans are high in iron, making them an excellent dietary choice for iron deficiency anemia. Milk can inhibit iron absorption due to calcium, raisins have less iron than beans, and tea contains tannins that reduce iron absorption.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Scatter rugs are present in the kitchen,
- B. Handrails are present in the bathroom.
- C. Electrical cords are placed along the walls.
- D. Uses a microwave for cooking.
Correct Answer: A
Rationale: Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment. Handrails provide support and help prevent falls, making them a safety feature, not a risk. Electrical cords placed along walls reduce tripping hazards. A microwave is generally safer than a stove, reducing the risk of burns and fires.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
- A. Allergic
- B. Acute pain
- C. Febrile
- D. Hemolytic
Correct Answer: D
Rationale: A hemolytic reaction involves red blood cell destruction, leading to fever, chills, and red-tinged urine due to hemoglobin in the urine, indicating a serious reaction.