The parent of a child newly diagnosed with lactose intolerance is being taught by the nurse. Which food items identified by the parent indicate an understanding of foods to avoid?
- A. Popcorn, seeds, and any foods containing nuts.
- B. Milk, cheese, ice cream, and puddings.
- C. Wheat, rye, barley, and commercially baked goods.
- D. Eggs, ham, bacon, and canned meats.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:
- A. take baseline vital signs
- B. warm the blood to room temperature for 30 minutes before administering the transfusion
- C. have two nurses verify client identification, blood type, unit number, and expiration date of blood
- D. get consent signed for blood transfusion
Correct Answer: D
Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.
The working phase in a therapy group is usually characterized by which of the following?
- A. Caution
- B. Cohesiveness
- C. Confusion
- D. Competition
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:
- A. Beneficence
- B. Non malfeasance
- C. Justice
- D. Double effect
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?
- A. Ensure that the bed linen is always dry
- B. Frequently check the bed for wetness and keep it dry
- C. Place a rubber sheet under the client's buttocks
- D. Keep the patient clean and dry
Correct Answer: A
Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.
A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription which reads, 'Discontinue NPO status; advance diet as tolerated.' Which of the following are appropriate for the nurse to offer the client? (SATA)
- A. Wheat toast
- B. Applesauce
- C. Applesauce, Chicken broth
- D. Chicken broth
Correct Answer: C
Rationale: The correct answer is C: Applesauce and chicken broth. After an appendectomy, patients are typically started on a clear liquid diet before advancing to more solid foods. Applesauce and chicken broth are part of a low-residue diet that is easily digestible and gentle on the digestive system, making them suitable choices for a client following surgery. Wheat toast may be too heavy and fibrous initially, while other solid foods should be introduced gradually to prevent gastrointestinal upset.