Nokea
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.
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A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?
- A. Consume foods high in potassium
- B. Avoid smoking tobacco products
- C. increase oral intake of water
- D. Limit alcohol to two drinks daily
Correct Answer: B
Rationale: Smoking impairs blood flow to the cochlea and auditory nerve, increasing hearing loss risk. Potassium, hydration, and moderate alcohol are not directly linked to hearing loss prevention.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer
- B. should check my skin monthly for any changes.
- C. should use sunscreen even on cloudy days.
- D. should avoid the use of tanning booths.
Correct Answer: A
Rationale: There is no evidence that a high-fiber diet reduces skin cancer risk, indicating a misunderstanding. Other statements reflect correct preventive measures.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
- A. Hemolytic
- B. Allergic
- C. Febrile
- D. Bacterial
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. 2 hr after obtaining blood from the blood bank
- B. When the client states he is ready to start the infusion
- C. As soon as the nurse can prepare the client and the administration set
- D. when the client has finished eating lunch
Correct Answer: C
Rationale: Blood products should be infused as soon as possible after preparation, ideally within 30 minutes, to reduce bacterial contamination risk and ensure efficacy.