Nokea
The nurse has taught a client who has been ordered a high in phosphorus diet about appropriate food choices. Which of the following food choices by the client would indicate a correct understanding of the teaching?
- A. Leafy greens
- B. Garlic
- C. Nuts
- D. Butter
- E. Turkey
Correct Answer: C, E
Rationale: Nuts and turkey are high in phosphorus, suitable for a high-phosphorus diet.
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The nurse is triaging a child with suspected impetigo. Which action should the nurse take?
- A. Initiate droplet precautions
- B. Set up a decontamination room
- C. Use a disposable blood pressure cuff
- D. Initiate contact precautions
- E. Apply sterile gloves while examining the client
Correct Answer: D, E
Rationale: Impetigo requires contact precautions and sterile gloves to prevent spread during examination.
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 in the emergency department (ED) is caring for a 10-year-old client.
Item 5 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
- A. Identify the child by only checking their identification armband.
- B. Apply a cold compress to the area to promote vasodilation.
- C. Demonstrate the procedure using a stuffed animal.
- D. Allow the child to decide which arm they would like for the venipuncture.
- E. Ask the child if they want to help set up some equipment.
- F. Offer the child a sedative to help them relax before the procedure.
Correct Answer: C, D, E
Rationale: Demonstrating on a stuffed animal, allowing arm choice, and involving the child in setup reduce anxiety and promote cooperation. Cold compresses constrict vessels, and sedatives are not routinely offered.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. captopril for a client with congestive heart failure
- B. metoprolol for a client with multiple premature ventricular contractions (PVCs)
- C. verapamil for a client with atrial fibrillation
- D. spironolactone for a client with end-stage renal disease
Correct Answer: D
Rationale: Spironolactone can cause hyperkalemia, which is dangerous in end-stage renal disease, and should be questioned.
The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?
- A. Sterile gloves should be used to perform urinary catheter care.
- B. Urinary specimens may be collected from a catheter bag.
- C. You may irrigate a catheter with warm water for poor outflow.
- D. Daily use of soap and water should be used around the urinary meatus.
Correct Answer: D
Rationale: Daily soap and water cleaning around the urinary meatus prevents infection. Sterile gloves are not required, specimens from catheter bags are unreliable, and irrigation requires a prescription.