Nokea
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: Cucumber salad contains seeds and roughage, which can irritate the colon in diverticulosis and should be avoided.
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The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
- A. Adjust the room temperature
- B. Give a bolus of IV fluids
- C. Start O2
- D. Administer meperidine (Demerol) 75 mg IV push
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
The nurse is preparing to administer a dose of prednisone (Deltasone) to a client with rheumatoid arthritis. The client asks, “Why do I need to take this medication?” Which of the following responses by the nurse is correct?
- A. It helps reduce inflammation and joint pain.
- B. It prevents infections in your joints.
- C. It increases calcium absorption in your bones.
- D. It promotes muscle strength.
Correct Answer: A
Rationale: prednisone is a corticosteroid that reduces inflammation and pain in rheumatoid arthritis
The nurse is caring for a client receiving IV heparin therapy for a pulmonary embolism. Which lab values would the nurse expect to order on this client?
- A. hematocrit
- B. HDL and LDL
- C. PT, PTT, INR
- D. troponin level
Correct Answer: C
Rationale: PT, PTT, and INR are monitored to assess the therapeutic effect and safety of heparin, which affects blood clotting.
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.