Nokea
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Assess nail beds for color and refill
- B. Assess for postoperative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.
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A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?
- A. Most of my calories each day should be from fats.
- B. I should eat more calories from complex carbohydrates than anything else.
- C. Simple sugars are needed more than other calorie sources.
- D. Protein should be my main source of calories.
Correct Answer: B
Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.
A nurse is reinforcing teaching to transition from breastfeeding to whole milk with the parents of an infant. Which of the following months of age should the nurse recommend for transitioning the infant to whole milk?
- A. 6 months
- B. 8 months
- C. 10 months
- D. 12 months
Correct Answer: D
Rationale: The correct answer is D: 12 months. Whole milk should be introduced at 12 months to ensure the infant's digestive system can handle the increased fat content. Introducing whole milk before 12 months can lead to digestive issues and potential allergies. Choices A, B, and C are incorrect because transitioning to whole milk before 12 months is not recommended for infants due to their digestive system still developing and not being able to handle the higher fat content of whole milk.
Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness
Correct Answer: D
Rationale: The correct answer is D, a preschooler with intermittent alertness. This client may not have the cognitive ability to effectively use a PCA pump due to their age and alertness level. They may not understand how to self-administer the analgesia. Choices A, B, and C are more appropriate candidates for PCA as they are likely to have better comprehension and ability to operate the PCA pump compared to a preschooler with intermittent alertness.
During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?
- A. Wash hands thoroughly before and after client contact
- B. Wear gloves when in contact with body secretions
- C. Double glove when in contact with feces or vomitus
- D. Wear gloves when disposing of contaminated linens
Correct Answer: A
Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?
- A. Boiled rice
- B. Italian bread
- C. Broiled salmon filet
- D. Pickled beets
Correct Answer: D
Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.