Nokea
A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?
- A. Walk for at least 30 minutes each day
- B. Avoid sunlight exposure
- C. Take vitamin B12 supplements
- D. Increase calcium intake to 1,500 mg per day
Correct Answer: D
Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.
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While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?
- A. A two-day old newborn with a respiratory rate of 70.
- B. A 16-hour old newborn who has not passed meconium yet.
- C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
- D. A 16-hour old newborn with a blood glucose of 45 mg/dL.
Correct Answer: A
Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.
A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?
- A. Administer an antiemetic
- B. Irrigate the NG tube with sterile water
- C. Increase the suction setting
- D. Replace the NG tube
Correct Answer: B
Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
- A. Take the client to the dining room with 1:1 supervision
- B. Inform the client they may go to the dining room when they control their behavior
- C. Hold the meal until the client is able to come out of seclusion
- D. Serve the meal to the client in the seclusion room
Correct Answer: D
Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.
A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
- A. Abdominal pain radiating to the right shoulder.
- B. Absent bowel sounds.
- C. Brown drainage on the surgical dressing.
- D. Urine output of 25 mL/hr.
Correct Answer: D
Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.
What is the proper technique for measuring a patient's blood pressure?
- A. Place the cuff at heart level and listen for Korotkoff sounds
- B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
- C. Use a manual sphygmomanometer and measure blood pressure on both arms
- D. Monitor pulse rate and apply pressure to the brachial artery
Correct Answer: A
Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.