Nokea
A nurse is reinforcing dietary teaching with a client who is postoperative and adheres to a vegetarian diet. Which of the following foods should the nurse recommend to the client as containing the highest amount of protein?
- A. Tomato soup
- B. Bananas
- C. Avocado
- D. Black beans
Correct Answer: D
Rationale: Black beans are a rich source of plant-based protein, making them the best recommendation for a vegetarian client needing protein post-surgery.
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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?
- A. Perform breast self-examinations during the middle of your cycle.
- B. Perform breast self-examinations while lying on your side.
- C. Use small, circular motions, working vertically up and down across the breast.
- D. Use the palm of your hand to detect the presence of any large masses under the skin.
Correct Answer: C
Rationale: Using small, circular motions in a vertical pattern is the correct technique for breast self-examination, making this an appropriate statement.
A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can season food with ketchup.
- B. I can season food with vinegar.
- C. I can have a bologna sandwich
- D. I can have canned soup.
Correct Answer: B
Rationale: Vinegar is low in sodium, unlike ketchup, bologna, or canned soup, aligning with hypertension dietary teaching.
A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
- A. Applesauce
- B. Orange slices
- C. Bran cereal
- D. Cottage cheese
Correct Answer: A
Rationale: Applesauce is gentle on the digestive system and helps firm stools, suitable for reintroducing solids after diarrhea.
A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter and record the client's output.
- B. Set up the equipment using clean technique.
- C. Prepare the client for a chest x-ray following the procedure.
- D. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.