Nokea
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
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The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply.
- A. Monitor temperature and report elevation.
- B. Recognize signs and symptoms of infection.
- C. Avoid crowds.
- D. Maintain integrity of skin and mucous membranes.
- E. Take a baby aspirin each day.
Correct Answer: A,B,C,D
Rationale: Leukemia increases infection risk due to impaired immune function. Monitoring temperature, recognizing infection signs, avoiding crowds, and maintaining skin/mucous membrane integrity are critical to prevent and detect infections. Baby aspirin is not indicated and may increase bleeding risk in leukemia.
The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
- A. Verify the client has signed an informed consent.
- B. Position the client in a side-lying position.
- C. Clean the skin with an antiseptic solution.
- D. Apply ice to the biopsy site.
Correct Answer: C,A,B,D
Rationale: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.
A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply.
- A. Reduces myocardial oxygen consumption.
- B. Promotes reduction in respiratory rate.
- C. Prevents ventricular remodeling.
- D. Reduces blood pressure and heart rate.
- E. Reduces anxiety and fear.
Correct Answer: A,D,E
Rationale: Morphine reduces pain, which lowers myocardial oxygen demand (A), decreases blood pressure and heart rate through vasodilation and reduced sympathetic response (D), and alleviates anxiety and fear (E). It does not prevent ventricular remodeling or directly reduce respiratory rate in this context.
A nurse is palpating a female client's breast while assessing for breast disease. In the illustration below, indicate the area of the breast in which tumors are most commonly found.
Correct Answer:
Rationale: Most breast tumors are found in the upper outer quadrant of the breast, as this area contains the most glandular tissue.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.