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The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?
- A. Check the client's blood pressure
- B. Assess the client's pain level
- C. Inspect the incision site
- D. Monitor the client's respiratory status
Correct Answer: C
Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.
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After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?
- A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: The most appropriate meal plan for a client following a myocardial infarction and placed on a sodium-restricted diet should include fresh ingredients with low sodium content to promote heart health. Option D, which consists of 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange, aligns best with these requirements. Option A contains canned beets, which are typically high in sodium. Option B includes canned salmon, which may have added sodium. Option C has a bologna sandwich, which is processed and high in sodium. Therefore, Option D is the most suitable choice for a client needing a low-sodium diet after a heart attack.
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.
The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.
A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be
- A. Cover the areas with dry sterile dressings
- B. Assess for dyspnea or stridor
- C. Initiate intravenous therapy
- D. Administer pain medication
Correct Answer: B
Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.
A nurse is assisting with the development of strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that doesn't apply).
- A. Avoid unpasteurized dairy products.
- B. Keep cold food temperatures below 4.4°C (40°F).
- C. Discard leftovers after 48 hours.
- D. Wash raw vegetables thoroughly in clean water.
Correct Answer: C
Rationale: The correct answer is C. Discarding leftovers after 48 hours is not an effective recommendation to prevent foodborne illnesses. Leftovers should actually be discarded within 2 hours if they have been at room temperature. Choices A, B, and D are all effective strategies to prevent foodborne illnesses: avoiding unpasteurized dairy products reduces the risk of harmful bacteria, keeping cold food temperatures below 4.4°C (40°F) inhibits bacterial growth, and washing raw vegetables thoroughly removes contaminants.