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The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- A. Roast beef sandwich, potato chips, pickle spear, iced tea
- B. Split pea soup, mashed potatoes, pudding, milk
- C. Tomato soup, cheese toast, Jello, coffee
- D. Hamburger, baked beans, fruit cup, iced tea
Correct Answer: B
Rationale: Soft foods like split pea soup, mashed potatoes, and pudding are easier to swallow for a client with a facial stroke, reducing the risk of aspiration.
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A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first
- A. place the client in high-Fowler's position in preparation to push.
- B. place the client in left lateral recumbent position.
- C. increase the rate of IV Pitocin.
- D. call the physician and report fetal distress.
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.
All of the following statements regarding scarlet fever are true EXCEPT
- A. rheumatic fever is a possible complication of scarlet fever.
- B. scarlet fever can be treated with antibiotics.
- C. a vaccine is available to protect against scarlet fever.
- D. scarlet fever is caused by an erythrogenic toxin.
Correct Answer: C
Rationale: No vaccine exists for scarlet fever, which is caused by Streptococcus pyogenes’ erythrogenic toxin and treated with antibiotics. Rheumatic fever is a complication.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
- A. 16-year-old female with scoliosis
- B. 12-year-old male with a fractured femur
- C. 10-year-old male with sarcoma
- D. 6-year-old male with osteomylitis
Correct Answer: B
Rationale: A 12-year-old male with a similar condition provides age-appropriate companionship and shared care needs.