Nokea
A woman in a residence facility is having difficulty sleeping at night. Which action by the nurse is most appropriate initially?
- A. Ask the physician for a sleeping medication
- B. Offer the woman a back rub and warm milk
- C. Suggest to the woman that she take a walk around the unit
- D. Offer the woman a cup of hot tea
Correct Answer: B
Rationale: A back rub and warm milk promote relaxation non-pharmacologically, addressing insomnia safely. Medication, walking, or tea (caffeine) are less appropriate.
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The nurse knows that the mother understands the dietary instructions for her toddler who has iron deficiency anemia when the mother selects which foods?
- A. Whole milk, carrots, and chicken pieces
- B. Ground beef, broccoli, and orange juice
- C. Liver, lima beans, and skim milk
- D. Macaroni and cheese, peas, and cola
Correct Answer: B
Rationale: Ground beef and broccoli are iron-rich, and orange juice (vitamin C) enhances iron absorption, ideal for iron deficiency anemia. Milk-heavy diets can inhibit iron absorption.
The nurse is responsible for teaching the client regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium?
- A. Apple
- B. Spinach
- C. Liver
- D. Squash
Correct Answer: B
Rationale: Spinach is a rich source of magnesium, found in green leafy vegetables, nuts, and whole grains. Apple , liver , and squash have lower magnesium content.
The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.