Nokea
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
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A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment of the client, the nurse would expect to find:
- A. Bradycardia
- B. Negative Chvostek's sign
- C. Hypertension
- D. Positive Trousseau's sign
Correct Answer: D
Rationale: Hypomagnesemia can cause a positive Trousseau's sign, indicating neuromuscular irritability due to low magnesium levels.
The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
- A. Rotating application sites
- B. Limiting applications to the chest
- C. Rubbing it into the skin
- D. Covering it with a gauze dressing
Correct Answer: A
Rationale: Rotating sites prevents skin irritation and ensures consistent absorption.
A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
- A. Delirium status.
- B. Vital signs.
- C. Oxygen saturation.
- D. Level of pain.
Correct Answer: D
Rationale: Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.
A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?
- A. It's normal to be scared. You are safe here. Let's discuss the procedure.
- B. I'll ask the cardiologist to come and speak with you about your concerns.
- C. We have the best outcomes of any facility in the area for this procedure.
- D. Don't worry. The procedure has improved a lot in the last 10 years.
Correct Answer: A
Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. 5 minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Correct Answer: D
Rationale: Chemical sunscreens require 30 minutes to absorb into the skin and provide effective UV protection.