Nokea
Anne asks how she developed iron deficiency anemia. You respond by saying
- A. Insomnia.
- B. An increase in iron intake.
- C. Heavy menses or an inadequate intake of iron.
- D. Low salt intake.
Correct Answer: C
Rationale: Iron deficiency anemia is commonly caused by blood loss or insufficient dietary intake.
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Mr. Jones has a scleral buckling procedure for repair of his retinal detachment. He states that he can see quite well now and wants to know if his vision will continue to improve. Which reply by the nurse would be most appropriate?
- A. It will be important to monitor your progress over the next 2 months.'
- B. Your eye should be fine provided that you do everything your doctor has told you.'
- C. There is no way of predicting whether or not this will recur.'
- D. You seem worried that this condition may recur.'
Correct Answer: A
Rationale: Monitoring progress over time is essential after retinal surgery, as visual improvement varies and requires ongoing assessment to ensure optimal outcomes.
What prevents disorientation in older clients with hearing impairments?
- A. Use of written notes and a walking cane for proper balance
- B. Refer to a local support or self-help group
- C. Frequent contact and reorientation
- D. Avoid frequent outdoor activities
Correct Answer: C
Rationale: Regular reorientation and interaction help maintain cognitive and spatial awareness.
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?
- A. The student should use his quick-relief inhaler.
- B. The student's asthma is not well controlled.
- C. The student's peak flow is 50% to 80% of his best peak flow.
- D. The student needs to go to the hospital
Correct Answer: D
Rationale: The correct answer is D because the student being in the yellow zone indicates moderate symptoms, not severe enough to necessitate hospitalization. A: Using a quick-relief inhaler is appropriate for yellow zone symptoms. B: Yellow zone indicates asthma is not well controlled, supporting the need for action. C: Peak flow of 50% to 80% signals a reduction in lung function, requiring intervention but not immediate hospitalization. Thus, D is the incorrect choice because hospitalization is not warranted for yellow zone symptoms.
For your patient with a CD4 count, less than 200, the most important nursing assessment would include
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: Fever can indicate opportunistic infections in immunocompromised patients.
Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)
- A. Check fingerstick glucose every hour
- B. Record intake and output every hour
- C. Check vital signs every 15 minutes
- D. Assess for indicators of fluid imbalance
Correct Answer: A
Rationale: Checking fingerstick glucose and recording intake/output are routine tasks that can be delegated to a nursing assistant. Assessing fluid imbalance and checking vital signs frequently require more skilled nursing judgment.