Nokea
The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
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The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 5 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
Which of the following instructions should the nurse include when teaching the client how to ambulate with a walker? Select all that apply.
- A. The top of the walker should line up with your wrist crease.
- B. Lean over the walker to maintain good balance.
- C. When going up the stairs, advance the walker up onto the step first.
- D. When getting up from a chair, use the chair's armrests to push yourself up.
- E. Move the walker forward 2 to 4 inches with each step.
Correct Answer: A,D
Rationale: The walker should align with the wrist crease for proper height, and using chair armrests ensures safe standing. Leaning over the walker risks imbalance, and the walker follows the stronger leg on stairs.
The nurse has obtained a client's blood pressure. The nurse recognizes that which of the following factors may increase a client's blood pressure?
- A. Nicotine patch application
- B. Heat exhaustion
- C. Performing deep breathing exercises
- D. Hypothyroidism
Correct Answer: A
Rationale: Nicotine, a vasoconstrictor, increases blood pressure. Heat exhaustion, deep breathing, and hypothyroidism typically lower or do not affect BP acutely.
The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?
- A. BUN level
- B. Prothrombin time
- C. Creatinine level
- D. Viral load
Correct Answer: B
Rationale: Prothrombin time assesses clotting, critical post-oral surgery to monitor bleeding risk. BUN and creatinine assess kidney function, and viral load is irrelevant.
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.