If the literature supplied by the fast-food chain indicates that one hot apple pie contains 2 g of protein, 14 g of fat, and 31 g of carbohydrates, how many calories are contained in one hot apple pie?
- A. 250 calories
- B. 260 calories
- C. 270 calories
- D. 280 calories
Correct Answer: C
Rationale: Calories are calculated as: (2 g protein × 4 kcal/g) + (14 g fat × 9 kcal/g) + (31 g carbohydrates × 4 kcal/g) = 8 + 126 + 124 = 258 kcal, closest to 270 kcal.
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Which assessment finding offers the best evidence that the client can tolerate the activity involved in getting out of bed?
- A. The client's appetite has improved.
- B. The client reports a more restful sleep.
- C. The client's heart rate is stable.
- D. The client can get out of bed without assistance.
Correct Answer: C
Rationale: Stable heart rate indicates the heart can handle the increased demand of activity.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.
Based on the client's complaint, the nurse would expect the pain to have which possible effect on the vital signs?
- A. Temperature may be elevated.
- B. Pulse rate may become rapid.
- C. Respiratory rate may slow.
- D. Blood pressure may fall.
Correct Answer: B
Rationale: Acute pain activates the sympathetic nervous system, increasing pulse rate due to stress response.
When obtaining a health history from the client, the nurse would expect to learn that which of the following was the client's earliest symptom?
- A. Anorexia
- B. Dyspnea
- C. Nausea
- D. Headaches
Correct Answer: B
Rationale: Dyspnea is often the earliest symptom of left-sided heart failure due to pulmonary congestion.
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
- A. Administer a radioisotope as ordered.
- B. Give the client a cleansing enema.
- C. Locate and mark peripheral pulses.
- D. Encourage high fluid intake before the test.
Correct Answer: C
Rationale: Locating and marking peripheral pulses before cardiac catheterization allows for post-procedure comparison to detect complications like arterial occlusion. Radioisotopes, enemas, and high fluid intake are not standard preparations for this procedure.
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