Nokea
The nurse has attended a staff education program about various types of diets. The nurse recognizes that which diet would place a client at the highest risk for megaloblastic anemia?
- A. lactoovovegetarian
- B. lactovegetarian
- C. ovovegetarian
- D. vegan
Correct Answer: D
Rationale: A vegan diet excludes all animal products, including vitamin B12 sources, which can lead to megaloblastic anemia if not supplemented. Other diets include dairy or eggs, which provide some B12.
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Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse
- A. attaches the drainage tubing to a leg collection bag
- B. retracts the foreskin before applying the condom sheath
- C. assesses the condition of the penile skin prior to application
- D. leaves a 1- to 2-inch (2.5- to 5-cm) space at the tip of the condom
Correct Answer: B
Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.
The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?
- A. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge
- B. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device
- C. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism
- D. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Correct Answer: A
Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.
A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?
- A. Age of the child
- B. Sibling position in family
- C. Stressful family events
- D. Parental discipline strategies
Correct Answer: A
Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.
A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?
- A. Riding in a car
- B. Falling off a bed
- C. An electrical outlet
- D. Eating peanuts
Correct Answer: D
Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.