Nokea
The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?
- A. irregular respirations
- B. abdominal respirations
- C. shallow respirations
- D. 70 breaths per minute
Correct Answer: D
Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.
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How can a diet high in fiber content benefit an individual?
- A. aid in rapid weight loss.
- B. reduce diabetic ketoacidosis.
- C. lower cholesterol.
- D. reduce the requirement for folate.
Correct Answer: C
Rationale: A diet high in fiber content can help lower cholesterol levels. Fiber-rich foods such as grains, apples, potatoes, and beans are known to aid in reducing cholesterol by binding to cholesterol in the digestive system and preventing its absorption into the bloodstream. Choice A is incorrect as the question does not specify losing weight rapidly but rather focuses on the benefits of a high-fiber diet, which includes aiding in weight management through promoting satiety and regulating digestion. Choice B is incorrect because while fiber helps manage blood sugar levels, it is not directly related to reducing diabetic ketoacidosis, a serious complication of diabetes. Choice D is incorrect as a high-fiber diet does not reduce the need for folate; however, it can aid in the absorption of folate and other essential nutrients.
A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?
- A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
- B. Complete the postpartum assessment and then give the client pain medication.
- C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
- D. Instruct the patient to do relaxation exercises to relieve her discomfort.
Correct Answer: C
Rationale: Pain management is a priority, so the nurse should immediately provide pain medication. However, the nurse should conduct a quick assessment while administering the medication to ensure that a complication, such as hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Controlling pain will enable the client to move, eliminating other potential complications of delivery and facilitating bonding with the infant. Relaxation techniques can act as an adjunct therapy but by themselves are not usually effective for pain management during the early post-Caesarean period.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. Within normal limits, so a weight-reduction diet is unnecessary.
- B. Lower than normal, so education about nutrient-dense foods is needed.
- C. Indicating obesity because the BMI is 35.
- D. Indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.
A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:
- A. is normal if the level is 4.0 to 5.5 mg/dl.
- B. can be elevated with increased protein intake.
- C. is a better indicator of renal function than the BUN.
- D. reflects the fluid volume status of a person
Correct Answer: C
Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Choice A is incorrect as a serum creatinine level of 4.0 to 5.5 mg/dl is not normal. Choice B is incorrect as serum creatinine is not affected by increased protein intake. Choice D is incorrect as serum creatinine primarily reflects renal function, not fluid volume status.
Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?
- A. Vitamin intake
- B. Body functions
- C. Defense mechanisms
- D. Disease cure
Correct Answer: C
Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.