Nokea
A nurse is taking care of a client with acute peritonitis. The nurse should do which of the following to meet the client's nutritional needs?
- A. administer feedings via nasogastric (NG) tube
- B. administer gastric enteral feedings
- C. feed the client orally
- D. administer parenteral nutrition
Correct Answer: D
Rationale: Acute peritonitis often requires bowel rest due to inflammation, making oral or enteral feedings inappropriate. Parenteral nutrition is indicated to meet nutritional needs.
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The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor?
- A. PT and PTT
- B. CBC
- C. BUN
- D. Liver enzymes
Correct Answer: D
Rationale: Isoniazid can cause hepatotoxicity, making liver enzyme monitoring critical.
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
The nurse is providing dietary education to a client with renal failure who is receiving hemodialysis. The nurse determines that the teaching has been effective when the client selects which items from the menu?
- A. Blueberries, cream of wheat, coffee
- B. Bacon, banana, orange juice
- C. Sausage, eggs, tomato juice
- D. Cured pork, grits, kiwi
Correct Answer: A
Rationale: Blueberries and cream of wheat are low in potassium and phosphorus, suitable for renal failure. The other options contain high-potassium or high-phosphorus foods (e.g., banana, orange juice, tomato juice).
The nurse is teaching a client with hypertension about dietary modifications. Which of the following statements by the client would require follow-up?
- A. I'm glad I can still eat beef and pork daily.
- B. I will need to get used to eating fruits and vegetables.
- C. I should avoid eating canned foods.
- D. I already told my spouse to buy me some yogurt when I get home.
Correct Answer: A
Rationale: Daily consumption of red meats like beef and pork is not recommended for hypertension due to high sodium and fat content.