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Client is a physical trainer, weighs 220 lb, requires an increase of protein by 20 g/kg/day, has taken 0.8 g of protein/kg/day in the past
How much total protein/day should the nurse recommend? Be sure to enter the number AND the unit of measurement (g).
Correct Answer: 2200 g
Rationale: The correct answer is 2200 g/day. This meets the recommended daily protein intake for an average adult, which is around 0.8 g/kg of body weight. For a 70 kg adult, this would be 56 g of protein per meal, totaling 168 g/day. Adding a margin for increased protein needs in certain conditions, such as illness or intense physical activity, brings the total to around 2200 g/day. Other choices are incorrect because they do not meet the recommended daily protein intake for adults and may lead to deficiencies or excess intake.
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Client pregnant, taking iron supplements for iron-deficiency anemia, reports black stools, no abdominal pain or cramping
Which of the following responses by the nurse is appropriate?
- A. What else have you been eating?
- B. Go to the emergency room and your provider will meet you there.
- C. This is expected because of the way iron is broken down during digestion.
- D. Come to the office and we will check things out.
Correct Answer: C
Rationale: The correct answer is C because it provides an appropriate explanation for the situation. Iron is known to cause dark stools due to its breakdown in the digestive system. This response shows understanding and reassures the patient. Choice A is relevant but doesn't address the specific issue. Choice B is inappropriate as it suggests an unnecessary visit to the emergency room. Choice D is a general invitation without addressing the concern.
Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the goal of managing type 2 diabetes through regular physical activity. Exercise helps control blood sugar levels and improves insulin sensitivity. Limiting exercise can lead to poor diabetes management. Choice A shows understanding of carbohydrate control. Choice B indicates adherence to medication regimen. Choice D demonstrates awareness of diabetes risk.
Client pregnant, BMI of 26.5
Which of the following statements is an appropriate response by the nurse?
- A. A gain of about 25 to 35 pounds is best for you and for your baby.
- B. The recommendation for you is about 15 to 25 pounds.
- C. You should gain 11 to 20 pounds.
- D. It really doesn't matter exactly how much weight you gain, as long as your diet is healthy.
Correct Answer: B
Rationale: The correct answer is B because the recommended weight gain during pregnancy varies based on pre-pregnancy weight. For a normal weight woman, gaining 25 to 35 pounds is ideal. However, for an underweight woman, it's recommended to gain 28 to 40 pounds, and for an overweight woman, 15 to 25 pounds is advised. Choice A is incorrect as it does not consider individual differences. Choice C is too narrow and may not be applicable to all women. Choice D is incorrect because weight gain does matter for both the mother and baby's health outcomes.
Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.
Client at 34 weeks of gestation, suspected placenta previa
Which of the following actions should the nurse take?
- A. Perform a rectal exam.
- B. Apply an external fetal monitor.
- C. Complete a vaginal exam.
- D. Apply ice to the perineal area.
Correct Answer: B
Rationale: The correct answer is B: Apply an external fetal monitor. This action is crucial in monitoring the fetal heart rate and uterine contractions during labor, ensuring the well-being of both the mother and the baby. Performing a rectal exam (choice A) is not indicated in this context. Completing a vaginal exam (choice C) may be necessary but is not the immediate priority. Applying ice to the perineal area (choice D) is not relevant for fetal monitoring. Other choices are not provided.