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A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
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A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?
- A. Replace wet clothing with warmed blankets.
- B. Use an axillary thermometer to monitor the client's temperature.
- C. Assist the client to perform range-of-motion exercises.
- D. Administer an antihypertensive medication.
Correct Answer: A
Rationale: Replacing wet clothing with warmed blankets prevents hypothermia, a critical risk after a near-drowning incident.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.
A nurse is preparing to administer enoxaparin 1.5 mg/kg subcutaneously to a client who weighs 175 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 119
Rationale: The client's weight is 175 lb = 79.5 kg (175 ÷ 2.2). Dose = 1.5 mg/kg × 79.5 kg = 119.25 mg, rounded to 119 mg.