Nokea
The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
- A. Roast beef, mashed potatoes, and spinach
- B. Baked chicken, rice, and an apple
- C. Ham sandwich, chips, and whole wheat bread
- D. Spaghetti with meat sauce and garlic bread
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
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The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
- A. Persistent sadness
- B. Fever and chills
- C. Uterine tenderness
- D. Foul-smelling lochia
Correct Answer: A
Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
The nurse is caring for a client with a history of a hiatal hernia who is receiving Propulsid (cisapride). The nurse should monitor the client for:
- A. Arrhythmias
- B. Hypotension
- C. Constipation
- D. Weight gain
Correct Answer: A
Rationale: Cisapride can prolong the QT interval, risking arrhythmias, requiring cardiac monitoring. Hypotension, constipation, and weight gain are not primary side effects.
A client with a history of heart failure is receiving Carvedilol (Coreg). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Tachycardia
- D. Weight gain
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause hypotension due to vasodilation and reduced heart rate. Hyperglycemia, tachycardia, and weight gain are not primary concerns.
Before completing a nursing diagnosis, the nurse must first:
- A. Write goals and objectives
- B. Perform an assessment
- C. Plan interventions
- D. Perform evaluation
Correct Answer: B
Rationale: Assessment is the first step of nursing process.