Nokea
A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?
- A. 1 tbsp of soft margarine
- B. ½ oz of nuts
- C. 2 tbsp of peanut butter
- D. 1 oz of sunflower seeds
Correct Answer: C
Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.
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A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct Answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?
- A. A heart rate of 72 beats per minute
- B. A blood pressure of 110/70 mm Hg
- C. Pupils equal and reactive to light
- D. Client reports headache
Correct Answer: C
Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.
A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be
- A. Cover the areas with dry sterile dressings
- B. Assess for dyspnea or stridor
- C. Initiate intravenous therapy
- D. Administer pain medication
Correct Answer: B
Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?
- A. FHT 168 beats/min
- B. Temperature 100 degrees Fahrenheit
- C. Cervical dilation of 4 cm
- D. BP 138/88
Correct Answer: A
Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.
The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?
- A. Check the client's blood pressure
- B. Assess the client's pain level
- C. Inspect the incision site
- D. Monitor the client's respiratory status
Correct Answer: C
Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.