Nokea
A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select one that doesn't apply).
- A. Cottage cheese
- B. Milkshake
- C. Tuna fish
- D. Strawberries and bananas
Correct Answer: D
Rationale: The correct answer is D - Strawberries and bananas. Cottage cheese, milkshakes, and tuna fish are high in protein and calories, making them beneficial in preventing protein-energy malnutrition. However, strawberries and bananas are not as protein or calorie-dense compared to the other options, so they are not as effective in preventing malnutrition.
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The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place the client in the wheelchair for four hours each day
- B. Pad the bony prominences
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.
A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?
- A. Blood pressure of 130/80 mm Hg
- B. Respiratory rate of 20 breaths per minute
- C. Heart rate of 72 beats per minute
- D. Temperature of 98.6 degrees Fahrenheit
Correct Answer: B
Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.
A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?
- A. Figs
- B. Broccoli
- C. Stewed tomatoes
- D. Skim milk
Correct Answer: D
Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.