Nokea
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti with meat sauce
Correct Answer: C
Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.
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A client is receiving hospice and palliative care, including analgesia and other comfort measures. Which of the following indicates the client is undergoing life review? Select all that apply.
- A. The client looks through old photo albums.
- B. The client states that her analgesia is not adequate.
- C. The client reminisces about her children when they were young and her parenting skills.
- D. The client states that she is ready to die.
- E. The client states she does not want her children to have a funeral for her.
Correct Answer: A,C
Rationale: Looking at photos (A) and reminiscing about parenting (C) indicate life review, reflecting on past experiences. Other statements (B, D, E) relate to pain or end-of-life wishes.
The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client who is post-op day 2 from a spinal fusion at L34 with a pain level of 4 on a scale of 1-10
- B. a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
- C. a client who is 6 hours post-atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
- D. a client with a nasogastric tube in place who is complaining of gastric distress
Correct Answer: C
Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct Answer: A
Rationale: Crystals in IV fluorouracil indicate precipitation; the solution should be discarded to prevent administration errors.
A 52-year-old client is undergoing menopause. Which of the following physical sign or symptom is often attributed to decreased estrogen production associated with menopause?
- A. Weight loss
- B. Excessive sleeping
- C. Increased fat deposits on hips and abdomen
- D. Increased metabolic rate
Correct Answer: C
Rationale: Decreased estrogen in menopause often leads to increased fat deposits on hips and abdomen (C). Weight loss (A), excessive sleeping (B), and increased metabolic rate (D) are not typical.
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.