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The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
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When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.
When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply.
- A. Take and record daily pulse rate.
- B. Avoid air travel because of airport security alarms.
- C. Immobilize the affected arm for 4 to 6 weeks.
- D. Avoid using a microwave oven.
- E. Avoid lifting anything heavier than 3 lb.
Correct Answer: A,E
Rationale: Daily pulse checks (A) monitor pacemaker function, and avoiding heavy lifting (>3 lb, E) prevents lead dislodgement. Air travel and microwaves are safe with modern pacemakers.
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.
The nurse is preparing to administer medication to a client. After verifying the right medication, dose, route, and time, the nurse should
- A. confirm the client's identity using two client identifiers.
- B. explain the purpose and potential side effects of the medication to the client.
- C. ensure the medication is within its expiration date.
- D. document the medication administration in the client's medical record.
Correct Answer: A
Rationale: Confirming client identity is the next step after verifying medication details to ensure safety.