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A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
- A. Tomatoes
- B. Carrots
- C. Avocados
- D. Apricots
Correct Answer: A
Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.
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Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?
- A. Serum albumin level of 3 g/dL
- B. Braden scale score of 20
- C. Norton scale score of 18
- D. Hemoglobin level of 13 g/dL
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.
While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?
- A. A two-day old newborn with a respiratory rate of 70.
- B. A 16-hour old newborn who has not passed meconium yet.
- C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
- D. A 16-hour old newborn with a blood glucose of 45 mg/dL.
Correct Answer: A
Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.
A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?
- A. Administer pain medication
- B. Reposition the client's leg
- C. Elevate the client's leg
- D. Check the client's neurovascular status
Correct Answer: D
Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.
A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?
- A. Ensure the chest tube is periodically clamped
- B. Check for air leaks in the tubing
- C. Keep the client in a prone position for chest drainage
- D. Administer diuretics to prevent fluid buildup
Correct Answer: B
Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.
What are the key nursing interventions for a patient undergoing dialysis?
- A. Monitor fluid balance and administer heparin
- B. Monitor blood pressure and prevent clot formation
- C. Administer medications and monitor blood chemistry
- D. Provide dietary education and encourage protein intake
Correct Answer: A
Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.