Nokea
The nurse is caring for a client with a history of chronic kidney disease.
- A. Which dietary restriction is most important for a client with chronic kidney disease?
- B. Low-sodium diet.
- C. Low-carbohydrate diet.
- D. High-protein diet.
- E. High-fat diet.
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention and hypertension in chronic kidney disease. Protein is restricted, carbohydrates are encouraged, and high-fat diets are not indicated.
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The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
A client is admitted with rheumatoid arthritis. Which symptoms, if exhibited by the client, are most consistent with the admitting diagnosis?
- A. A 72-year-old with pain, redness, and swelling in the big toes
- B. A 68-year-old with enlarged finger joints and pain in the knees
- C. A 34-year-old with joint pains and a red rash on the cheeks
- D. A 28-year-old with enlarged joints and painful muscles
Correct Answer: B
Rationale: Rheumatoid arthritis causes symmetrical joint inflammation, leading to enlarged, painful joints like fingers and knees. Toe pain suggests gout, rash suggests lupus, and muscle pain is less specific.
A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
- A. This Test is performed by sticking my finger and measuring the results.
- B. This Test needs to be performed in the morning before I eat breakfast.
- C. This Test indicates how well my blood sugar has been controlled the past 6-8 weeks.
- D. I must follow my diet carefully for several days before the Test .
Correct Answer: C
Rationale: when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
- A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
- B. A 65-year-old who had hip replacement surgery two days ago
- C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
- D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Correct Answer: A
Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.