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The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
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The NA tells the nurse that the unit's small-adult BP cuff cannot be found and that the client's arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?
- A. Document the other vital signs and note that the proper-fitting BP cuff is not available.
- B. Go to another nursing unit to obtain their small-adult BP cuff, and take the client's BP.
- C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings.
- D. If the cuff closes around the arm, take the client's BP using the regular adult cuff.
Correct Answer: B
Rationale: B: A correct-sized cuff ensures accurate BP readings. A: Omitting BP is inappropriate. C: Adjusting readings is inaccurate. D: A too-large cuff gives falsely low readings.
The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?
- A. Keep the infant fully clothed to prevent chilling and hypothermia.
- B. Cover the infant's eyes with eye shields to prevent retinal damage.
- C. Limit the number of feedings to reduce the number of soiled diapers.
- D. Discontinue the phototherapy if the infant develops a mild skin rash.
Correct Answer: B
Rationale: B: Eye shields protect retinas from phototherapy light. A: Clothing reduces skin exposure, hindering bilirubin conversion. C: Increased feedings aid bilirubin excretion. D: Mild rashes are harmless and don't warrant discontinuation.
The method of splinting is always dictated by:
- A. Location of the injury and whether it is open or closed
- B. The severity of the client's condition and the priority decision
- C. The number of available rescuers and the type of splints
- D. All of the above
Correct Answer: B
Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
- A. Encourage foods high in vitamin C such as orange juice
- B. Premedicate with analgesics prior to dressing changes
- C. Monitor pedal pulses and capillary refill of affected extremity
- D. Use hydrogen peroxide for cleaning of the ulcer wound
- E. Turn and reposition the client every 1 to 2 hours
- F. Elevate the extremity on pillows, keeping the heel off the pillow
Correct Answer: A,B,C,E,F
Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.