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An adult is on a clear liquid diet. Which food should the nurse offer him?
- A. A milkshake
- B. Fruited gelatin
- C. Sherbet
- D. Apple juice
Correct Answer: D
Rationale: Apple juice is a clear liquid, appropriate for a clear liquid diet. Milkshakes and sherbet contain dairy, and fruited gelatin may have solids, making them unsuitable.
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Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
- A. Supine and flat
- B. Prone with the hips slightly elevated
- C. Prone with the head slightly elevated
- D. Side lying
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
Triage refers to the classification of injury severity during a disaster. Which of the following clients should receive priority during triage?
- A. Open fractures of the tibia and fibula
- B. Burns of the head and neck
- C. Crushing injury of the arm
- D. Contusions and lacerations of the head without loss of consciousness
Correct Answer: B
Rationale: Burns to the head and neck are prioritized due to potential airway compromise, a life-threatening condition. Open fractures, crushing injuries, and minor head injuries are less immediately critical.
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery