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 has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.
- C. I keep my regular insulin bottle in the refrigerator.
- D. I always make sure to shake the NPH bottle hard to mix it well.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.
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.
After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.
Which information is a priority for the client to reinforce after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours as the preparation and test are tiring.
- C. During waking hours, drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure urine output for the next day and immediately notify the healthcare provider if it decreases.
Correct Answer: D
Rationale: After intravenous pyelography, monitoring urine output is crucial to assess kidney function and detect any early signs of complications. Decreased urine output could indicate a problem with kidney function or potential complications from the procedure. While rest and hydration are important, the priority lies in monitoring urine output for any abnormalities. Eating a light diet may be recommended, but it is not the priority post-procedure instruction.