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A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
- A. Chicken broth
- B. Flavored gelatin
- C. Cranberry juice
- D. Skim milk
Correct Answer: D
Rationale: The correct answer is D: Skim milk. Skim milk is allowed on a full liquid diet as it is easily digested and provides essential nutrients. It is also a good source of protein and calcium, important for healing post-surgery. Chicken broth (A) and flavored gelatin (B) are typically allowed on a clear liquid diet but may not be suitable for a full liquid diet. Cranberry juice (C) is acidic and may be too harsh on the stomach post-surgery. Therefore, the nurse should advise the client to choose skim milk for his meal tray to support healing and recovery.
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A nurse is caring for four clients who have drainage tubes. Which of the following clients is at risk for hypokalemia?
- A. The client who has a tracheostomy tube attached to humidified oxygen.
- B. The client who has an indwelling urinary catheter to gravity drainage.
- C. The client who has a chest tube to water seal.
- D. The client who has a nasogastric tube to suction.
Correct Answer: D
Rationale: The correct answer is D. The client with a nasogastric tube to suction is at risk for hypokalemia because suctioning can lead to loss of gastric contents, which contain potassium. This can result in decreased potassium levels in the body, leading to hypokalemia.
A: The client with a tracheostomy tube attached to humidified oxygen is not at risk for hypokalemia as oxygen therapy does not directly impact potassium levels.
B: The client with an indwelling urinary catheter to gravity drainage is not at risk for hypokalemia as urinary drainage does not affect potassium levels significantly.
C: The client with a chest tube to water seal is not at risk for hypokalemia as chest tube drainage does not lead to potassium loss.
In summary, choice D is correct because suctioning via a nasogastric tube can cause potassium loss, while choices A, B, and C are incorrect as they do not directly impact potassium levels.
A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
- A. Place a black tag on the client’s upper body and attempt to help the next client in need.
- B. Reposition the client’s upper airway a second time before assessing his respirations.
- C. Start CPR.
- D. Place a red tag on the client’s upper body and obtain immediate help from other personnel.
Correct Answer: A
Rationale: The correct answer is A: Place a black tag on the client’s upper body and attempt to help the next client in need. In this scenario, the client is apneic despite repositioning the airway and has a weak pulse. The client's condition falls under "expectant" during triage, indicated by a black tag. The nurse should prioritize helping those who have a higher chance of survival first. Placing a black tag and moving on to assist others is essential to maximize the number of lives saved in a mass casualty event. Starting CPR (choice C) may be futile if the client is trapped under a car with severe injuries. Choice B, repositioning the airway again, is unlikely to change the client's apneic status. Choice D, placing a red tag, is incorrect as this tag is typically used for immediate care cases.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)
- A. Botulism is acquired through direct contact with an infected person.
- B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed.
- C. Botulism can produce paralysis within 12 to 72 hours following exposure.
- D. Vomiting and diarrhea are expected findings following exposure.
- E. Botulism is a toxin found in castor beans.
Correct Answer: C,D
Rationale: The correct answers are C and D. Choice C is correct because botulism can indeed produce paralysis within 12 to 72 hours following exposure. This is crucial information for early detection and treatment. Choice D is also correct because vomiting and diarrhea are not typical symptoms of botulism. The toxin primarily affects the nervous system, leading to symptoms such as muscle weakness and paralysis. Choices A, B, and E are incorrect. Botulism is not acquired through direct contact with an infected person (A), the CDC should be notified immediately upon suspicion of botulism, not after a certain number of cases (B), and botulism toxin is not found in castor beans (E).
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.