Nokea
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
- A. Meat, eggs, dairy products
- B. Peanut butter, raisins, molasses
- C. Broccoli, cauliflower, cabbage
- D. Shrimp, legumes, bran cereals
Correct Answer: A
Rationale: Vitamin B12 is found in animal products like meat, eggs, and dairy, essential for treating pernicious anemia due to impaired B12 absorption.
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The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.
The physician has inserted an esophageal balloon tamponade in a client with bleeding esophageal varices. The nurse should maintain the esophageal balloon at a pressure of:
- A. 5-10 mmHg
- B. 10-15 mmHg
- C. 15-20 mmHg
- D. 20-25 mmHg
Correct Answer: D
Rationale: A pressure of 20-25 mmHg effectively compresses varices to control bleeding without causing tissue damage.
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
- A. Increased jaundice and prolonged prothrombin time
- B. Fever and foul-smelling bile drainage
- C. Abdominal distention and clay-colored stools
- D. Increased uric acid and increased creatinine
Correct Answer: A
Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.
Which of the following best describes the language of a 24-month-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of words
- C. Able to verbalize needs
- D. Asks 'why?' to most statements
Correct Answer: C
Rationale: A 24-month-old can verbalize needs using simple words or phrases, reflecting their developing language skills.
The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately?
- A. BP 82/60, pulse 120
- B. Pulse 68, respirations 24
- C. BP 110/88, pulse 56
- D. Pulse 82, respirations 16
Correct Answer: A
Rationale: A blood pressure of 82/60 and pulse of 120 indicate possible hypovolemic shock, likely due to gastrointestinal bleeding, which is a medical emergency requiring immediate reporting.