Nokea
The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
- A. high in fat
- B. low in sodium
- C. low in calories
- D. low in protein
Correct Answer: A
Rationale: High-fat meals provide necessary calories for cystic fibrosis patients with high energy needs.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a pregnant client.
Item 1 of 1
Nurses' Notes
Emergency Department
0735: Client reports sudden onset of nausea and vomiting, heavy vaginal bleeding with dark red blood, frequent low-intensity contractions, lower abdominal pain rated 9/10 on the Numerical Rating Scale for past two hours, and dull lower back pain rated 2/10 on the Numerical Rating Scale for the past 24 hours. Client is 30 weeks gestation (G=4 T=3 P=0 A=0 L=3) and is Rh-positive. Vital signs: T 99.8 ⁰ F (37.7 ⁰ C), P 99, RR 16, BP 112/76, pulse oximetry reading 94% on room air. Uterine tenderness present with gentle palpation. Client states they are a one-pack per day cigarette smoker and denies any alcohol or illicit drug use.
The nurse reviews the client's admission data to begin the plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. initiate electronic fetal monitoring (EFM), administer Rh immune globulin, assess for signs of hyperemesis gravidarum, start peripheral access device, perform an ultrasound examination
- B. placenta previa, preterm labor, placental abruption, preeclampsia
- C. continuous electronic fetal monitoring (EFM), 24-hour urine specimen, strict intake & output, vital signs, serum creatinine levels
Correct Answer: B (placental abruption), A (initiate EFM, start peripheral access device), C (fetal heart rate pattern, vital signs)
Rationale: The client's heavy vaginal bleeding, severe abdominal pain, and frequent contractions at 30 weeks suggest placental abruption. EFM and peripheral access are critical interventions, and monitoring fetal heart rate and vital signs assesses progress.
The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a
- A. serum total cholesterol 180 mg/dl (4.65 mmol/L)
- B. glycosylated hemoglobin (A1C) 7.5%
- C. serum calcium 9.2 mg/dl (2.30 mmol/L)
- D. serum creatinine 1.0 mg/dL (88.4 µmol/L)
Correct Answer: B
Rationale: An A1C of 7.5% is elevated for a client with diabetes mellitus (DM), as the target is typically ≤7%. This requires follow-up to assess glycemic control.
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
- A. Diaphoresis
- B. Sudden weight gain
- C. No wet diapers
- D. Hypoxia
- E. Increased appetite
Correct Answer: A, B, C, D
Rationale: Diaphoresis, sudden weight gain, no wet diapers, and hypoxia are early signs of heart failure in children.
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include?
- A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr (2.775 to 4.165 mmol/L/hr).
- B. Dextrose 5% in water (D5W) should be available to treat symptoms of hypoglycemia.
- C. Hypovolemia caused by DKA may be treated with 3% saline.
- D. The urine output would increase once regular insulin is initiated.
Correct Answer: A, B, D
Rationale: The goal is to lower glucose gradually, D5W treats hypoglycemia, and insulin increases urine output by correcting osmotic diuresis. 3% saline is not used for hypovolemia in DKA.
The nurse is admitting a new client and begins to review information regarding advanced directives. The client becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action?
- A. Leave the handout on the client's bedside table instructing him that he must review the content.
- B. Document the client's refusal, using the client's own words, in quotes.
- C. Explain to the client that he must make decisions about accepting or refusing treatment while in the hospital.
- D. Request an assessment of the client's competency related to making decisions about advanced directives.
Correct Answer: B
Rationale: Respecting the client's autonomy, the nurse should document the refusal accurately, using the client's words, without forcing the issue.