Nokea
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
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A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.
A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will have the bone marrow taken from your femur.
- B. I will hold pressure to the site after the procedure.
- C. You will not receive a local anesthetic agent for this procedure.
- D. You will need to fast for 2 hours before the procedure.
- E. The procedure will take 4 hours.
- F. You should avoid moving for 24 hours after.
- G. You'll feel intense pain throughout.
Correct Answer: B
Rationale: Pressure is applied post-procedure to prevent bleeding; marrow is typically taken from the iliac crest, local anesthetic is used, and fasting isn't required.
• Exhibit 1 Exhibit 2 Exhibit 3
• History and Physical
• 1000:
• Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
• For each finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Each finding may support more than 1 disease process.
A nurse in a provider's office is assisting in the care of a client. For each finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Which finding is most consistent with iron deficiency anemia?
- A. Ferritin level
- B. Fatigue
- C. Vitamin B level
- D. Orthostatic hypotension
Correct Answer: A
Rationale: Iron deficiency anemia stems from low iron, reducing hemoglobin synthesis, while sickle cell disease involves abnormal hemoglobin shape, and pernicious anemia results from Bâ‚â‚‚ malabsorption. Ferritin, the iron storage protein, is low in iron deficiency (e.g., <15 ng/mL), directly reflecting depleted reserves, as seen in the vegan client with fatigue and pale mucous membranes from Exhibit 1. Fatigue occurs across all three conditions nonspecific due to reduced oxygen delivery but isn't unique. Vitamin Bâ‚â‚‚ levels drop in pernicious anemia, not iron deficiency, unless dual deficiency exists, which isn't suggested. Orthostatic hypotension could arise in severe anemia from hypovolemia, but it's not specific to iron deficiency over others. Low ferritin aligns with iron deficiency's pathophysiology, distinguishing it from sickle cell's vaso-occlusion or pernicious anemia's megaloblastic changes, making it the most consistent finding per diagnostic criteria.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?
- A. Abdominal wound dry, without redness
- B. Client received an adequate amount of fluid
- C. Client status unchanged throughout shift
- D. Incision healing well
- E. Pain level stable
- F. No fever noted
- G. Ambulated without difficulty
Correct Answer: A
Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.