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The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
- A. Hamburger, French fries, and orange juice
- B. Sliced veal, spinach salad, and whole-wheat roll
- C. Vegetable lasagna, Caesar salad, and toast
- D. Bacon, lettuce, and tomato sandwich; potato chips; and tea
Correct Answer: B
Rationale: Veal and spinach are high in iron, and whole-wheat roll provides additional nutrients. The other meals lack significant iron sources.
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A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies
- B. Check the client's immunization record
- C. Apply a splint to immobilize the arm
- D. Administer medication for pain
Correct Answer: C
Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.
The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
- A. Decreased protein concentration with a normal cell count
- B. Increased protein concentration with a normal cell count
- C. Increased protein concentration with an abnormal cell count
- D. Decreased protein concentration with an abnormal cell count
Correct Answer: B
Rationale: Guillain-Barre syndrome typically shows elevated protein levels in cerebrospinal fluid with a normal cell count, known as albuminocytologic dissociation.
The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
- A. The need for oxygen therapy
- B. A history of claustrophobia
- C. A permanent pacemaker
- D. Sensory deafness
Correct Answer: C
Rationale: A permanent pacemaker is a contraindication for an MRI due to the risk of device malfunction in a magnetic field.
The nurse is teaching the mother of a newborn to care for the umbilical cord. What should the nurse advise the mother to do if the cord becomes soiled with urine or feces?
- A. Swab with alcohol.
- B. Wipe with a dry cloth.
- C. Wash with mild soap and water, rinse and dry.
- D. Swab with povidone-iodine.
Correct Answer: C
Rationale: Washing with mild soap and water, rinsing, and drying (C) cleans the umbilical cord safely without irritation. Alcohol (A) and povidone-iodine (D) may be too harsh, and a dry cloth (B) is ineffective.
Ideally, the first dose of what vaccine is given at birth?
- A. IPV
- B. Hib
- C. DTaP
- D. hepatitis B
Correct Answer: D
Rationale: The hepatitis B vaccine is recommended at birth to prevent perinatal transmission and establish early immunity.