Nokea
The health care provider (HCP) provides education to an adult client about an upcoming surgical procedure. The client states, 'I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy.' What action should the nurse take?
- A. Ask the client's family member to sign the consent form
- B. Inform the client that the HCP can discuss all questions after surgery
- C. Provide the client with educational materials about low-fat diet options
- D. Reinforce education about the procedure using a visual aid
Correct Answer: C
Rationale: Providing dietary education addresses the client's question directly. Family consent is inappropriate, postponing discussion delays clarification, and procedure education doesn't address diet.
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A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .
The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?
- A. I will exhale a complete breath as quickly as possible through the mouthpiece of the device to obtain a peak flow reading
- B. I will move the indicator to the desired reading on the numbered scale before using the device
- C. I will record the lowest of 3 consecutive peak flow readings in my asthma journal every day.
- D. I will remember to use the device after taking my fluticasone via metered-dose inhaler.
Correct Answer: A
Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.
A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.
- A. Apply occlusive dressings after rewarming
- B. Elevate affected extremities after rewarming
- C. Massage the areas to increase circulation
- D. Provide adequate analgesia
- E. Provide continuous warm water soaks
Correct Answer: B,D
Rationale: Elevation reduces swelling post-rewarming. Analgesia manages pain. Occlusive dressings trap moisture, massaging risks tissue damage, and continuous soaks may cause maceration.
The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.