Nokea
The nurse is caring for a client who is recovering from a fractured femur. Which diet selection would be best for this client?
- A. Loaded baked potato, fried chicken, and tea
- B. Dressed cheeseburger, French fries, and a Diet Coke
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Mandarin orange salad, broiled chicken, and milk
Correct Answer: D
Rationale: A diet for fracture recovery needs protein, calcium, and vitamin C. Mandarin orange salad (vitamin C), broiled chicken (protein), and milk (calcium) (D) are optimal. Other options are less nutrient-dense.
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A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Restricting fluid intake
- C. Increasing sensory stimuli
- D. Applying ankle and wrist restraints
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
- A. A positive blood
- B. B positive blood
- C. O negative blood
- D. AB negative blood
Correct Answer: C
Rationale: O negative blood is the universal donor type, safe for all recipients, including B negative, as it lacks A, B, and Rh antigens, minimizing transfusion reactions.
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Smooth, coordinated voluntary movement
- B. Tremors
- C. Rigidity
- D. Muscle weakness
Correct Answer: A
Rationale: Benztropine alleviates extrapyramidal side effects of tranquilizers, such as tremors and rigidity, resulting in smooth, coordinated movements.
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
- A. Add more water to the suction-control chamber.
- B. Remove the drainage using a 60 mL syringe.
- C. Milk the tubing to facilitate drainage.
- D. Prepare a new unit for continuing collection.
Correct Answer: D
Rationale: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.