Nokea
The nurse is caring for a client who is ordered to be on bed rest for a prolonged period of time. What should be included in the nursing care plan to prevent venous stasis?
- A. Deep breathe and cough every two hours
- B. Range-of-motion exercises every shift
- C. Antiembolism stockings on legs
- D. Turn every two hours
Correct Answer: C
Rationale: Antiembolism stockings promote venous return, preventing stasis in bedridden clients. Breathing exercises, ROM, and turning address other complications but not venous stasis directly.
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A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
- A. To increase oxygen to the brain
- B. To dilate the cerebral blood volume
- C. To increase the cerebral blood volume
- D. To promote cerebral vasoconstriction and decrease cerebral blood flow
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.
A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 30 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-nephrectomy complication. Options A, C, and D are normal or expected.
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is MOST appropriate?
- A. Limit exercise to once a week.
- B. Consume a high-sodium diet.
- C. Lose weight if overweight.
- D. Increase alcohol intake.
Correct Answer: C
Rationale: Weight loss reduces blood pressure in hypertensive clients. Options A, B, and D worsen hypertension.