Nokea
The nurse is caring for a client who has just undergone a cesarean section. Which of the following interventions is most important in the immediate postoperative period?
- A. Encouraging early ambulation.
- B. Administering oral fluids immediately.
- C. Monitoring for signs of infection.
- D. Applying heat to the incision site.
Correct Answer: A
Rationale: Encouraging early ambulation post-cesarean section prevents complications like deep vein thrombosis and promotes recovery.
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The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client for:
- A. Diarrhea.
- B. Constipation.
- C. Hoarseness.
- D. Weight gain.
Correct Answer: C
Rationale: Hoarseness is a common symptom of metastatic lung cancer due to tumor effects on the larynx or recurrent laryngeal nerve. Constipation, diarrhea, and weight gain are less specific.
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
- A. Sterile items ONLY are placed on the sterile field.
- B. The nurse must keep the sterile field below waist level.
- C. Coughing or sneezing over the sterile field contaminates the sterile field.
- D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
- E. Moisture and wetness contaminate the sterile field.
- F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.