Nokea
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?
- A. 3 oz chicken breast
- B. 3 oz canned tuna
- C. 3 oz pork roast
- D. 3 oz ground beef
Correct Answer: D
Rationale: Ground beef has the highest iron content (about 2.7 mg/3 oz) among these options, making it best for iron-deficiency anemia.
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A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase vitamin C intake by drinking orange juice.
- B. I will eat six small meals each day.
- C. I will lie down for 30 minutes after each meal.
- D. I will sleep flat on my back at night.
Correct Answer: B
Rationale: Six small meals reduce stomach pressure and reflux in GERD. Orange juice can worsen reflux, lying down post-meal increases it, and sleeping flat doesn't help.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Measure the client's intake and output every 8 hr.
- B. Dim the lighting in the client's room.
- C. Monitor the client's temperature every 6 hr.
- D. Initiate contact precautions for the client.
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. Experiences nocturia
- B. History of generalized anxiety disorder
- C. Recent exposure to tuberculosis
- D. Reports periodic migraine headaches
Correct Answer: C
Rationale: Recent TB exposure is the priority due to infection risk to others in a semi-private room, requiring immediate isolation precautions.