Nokea
A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?
- A. Pears
- B. Apples
- C. Bananas
- D. Cranberries
Correct Answer: C
Rationale: Triamterene is a potassium-retaining diuretic, and the client should avoid foods that are high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, oranges, mangoes, cantaloupe, strawberries, nectarines, papayas, and dried prunes.
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During the assessment, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?
- A. Document the child's physical findings.
- B. Report the case because abuse is suspected.
- C. Refer the family to appropriate support groups.
- D. Assist the family with identifying resources and support systems.
Correct Answer: B
Rationale: The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting the assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. Although the remaining options are appropriate, reporting the findings has priority.
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
- A. Determining the presence of client allergies
- B. Asking if the client has any last-minute questions
- C. Telling the client to try to void before leaving the unit
- D. Emphasizing to the client the importance of remaining still during the procedure
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.
A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period?
- A. Place the client on bed rest.
- B. Allow the client to ambulate only in the room.
- C. Obtain a bedside commode for the client's use.
- D. Encourage the client to be up at least twice per day.
Correct Answer: A
Rationale: The client is placed on aneurysm precautions, and the client's activity is kept to a minimum to prevent Valsalva's maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, the rest of the options are incorrect actions.
The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?
- A. Determining tube placement
- B. Auscultating the bowel sounds
- C. Measuring the intake and output
- D. Establishing the client's baseline weight
Correct Answer: A
Rationale: The nurse avoids injecting any substance into a client's NGT before verifying tube placement because NGTs can migrate out of the stomach. If the NGT is not in the correct location, subsequent injections or feedings through the tube can lead to serious complications such as aspiration. None of the remaining options are priorities before administering an enteral feeding.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.