Nokea
The first exercise that should be performed by the client who had a mastectomy 1 day earlier is:
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: Squeezing a ball is a gentle initial exercise to restore arm mobility.
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The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?
- A. High Fowler's position with the head tilted forward.
- B. High Fowler's position with the head tilted backward.
- C. Semi-Fowler's position with the head in a neutral position.
- D. Semi-Fowler's position with the head tilted backward.
Correct Answer: A
Rationale: High Fowler's position with the head tilted forward (A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B, D) or using a neutral position in semi-Fowler's (C) is less effective for this procedure.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
- A. Puffed wheat
- B. Banana
- C. Puffed rice
- D. Cornflakes
Correct Answer: A
Rationale: Puffed wheat contains gluten, which must be avoided in celiac disease to prevent intestinal damage.
A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
- A. Processed cheese
- B. Cottage cheese
- C. Cream cheese
- D. Cheddar cheese
Correct Answer: D
Rationale: Parnate, a monoamine oxidase inhibitor (MAOI), interacts with tyramine-rich foods like aged cheeses (e.g., cheddar) to cause hypertensive crisis due to increased norepinephrine release.