A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
- A. Fat
- B. Protein
- C. Glycogen
- D. Carbohydrates
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are the primary source of energy for the body, especially during high-intensity activities like sports. When consumed, carbohydrates are broken down into glucose, which is used for immediate energy or stored as glycogen in muscles and the liver for later use. Fat is a long-term energy reserve but is not as readily accessible as carbohydrates for quick energy. Protein is primarily used for building and repairing tissues, not as a main energy source. Glycogen is a stored form of carbohydrates in the body, not the primary energy reserve.
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A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
- A. Eating more protein is optimal prior to testing
- B. One stool specimen is sufficient for testing
- C. A red color change indicates a positive test
- D. The specimen cannot be contaminated
Correct Answer: D
Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners. Choice A is incorrect because protein intake does not affect the test. Choice B is incorrect as multiple stool specimens are usually required. Choice C is incorrect as a blue color change indicates a positive test, not red.
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
- A. Some clients exaggerate their level of pain
- B. Pain must have an identifiable source to justify the use of opioids.
- C. Objective data are essential in assessing pain
- D. Pain is whatever the client says it is.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take?
- A. Offer to assist the client needing the bedpan.
- B. Administer the injection prepared by the other nurse.
- C. Prepare another syringe & administer the injection.
- D. Tell the client needing the bedpan she will have to wait for her nurse.
Correct Answer: A
Rationale: The correct answer is A. The second nurse should offer to assist the client needing the bedpan. This is important for patient safety and continuity of care. By offering assistance, the second nurse ensures that the immediate needs of the client are met promptly. Administering the injection prepared by the other nurse (B) may lead to errors and violates the principle of accountability. Preparing another syringe and administering the injection (C) is unnecessary and could delay care for the client needing assistance. Telling the client needing the bedpan to wait (D) is not appropriate as it neglects the client's needs.
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?
- A. Give the client thin liquids.
- B. Instruct the client to tuck her chin when swallowing.
- C. Have the client use a straw.
- D. Encourage the client to lie down and rest after meals.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to tuck her chin when swallowing. This intervention helps prevent aspiration by closing off the airway during swallowing, reducing the risk of food or liquids entering the lungs. Tucking the chin also helps direct the food or liquid down the esophagus. Giving thin liquids (choice A) can increase the risk of aspiration. Using a straw (choice C) may also increase the risk by bypassing the natural protective mechanisms. Encouraging the client to lie down after meals (choice D) can lead to aspiration due to decreased muscle tone and gravity assisting in food or liquid entering the airway.