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The nurse is caring for a client with a history of pancreatitis.
- A. Which dietary instruction is most appropriate for a client with chronic pancreatitis?
- B. High-fat, low-protein diet.
- C. Low-fat, high-protein diet.
- D. High-carbohydrate, low-fat diet.
- E. Low-carbohydrate, high-fat diet.
Correct Answer: B
Rationale: A low-fat, high-protein diet reduces pancreatic stimulation and supports tissue repair in chronic pancreatitis. High-fat diets exacerbate symptoms, and carbohydrate balance is less critical.
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Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
- A. Sports and games with rules
- B. Finger paints and water play
- C. Dress-up clothes and props
- D. Chess and television programs
Correct Answer: A
Rationale: Sports and games with rules. The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.
The nurse is caring for a client with a history of osteoporosis.
- A. Which intervention is most effective for preventing fractures in a client with osteoporosis?
- B. Encourage weight-bearing exercises.
- C. Administer vitamin C supplements.
- D. Restrict calcium intake.
- E. Encourage bed rest to prevent falls.
Correct Answer: A
Rationale: Weight-bearing exercises strengthen bones, reducing fracture risk in osteoporosis. Vitamin C is less critical than calcium and vitamin D, calcium restriction worsens bone loss, and bed rest increases bone resorption.
A client receiving Gentamycin (garamycin) IVPB has a morning peak level of 12 μg/mL. The nurse should:
- A. Notify the physician because the level is too high.
- B. Administer the medication at the scheduled time.
- C. Request an order to administer the medication IM.
- D. Repeat the level 30 minutes before the next dose.
Correct Answer: A
Rationale: The nurse should notify the physician because the level is too high (therapeutic range for Garamycin is 4-10 μg/mL). Answers B and C are incorrect because they would increase the peak level. Answer D refers to the time for drawing a trough level, making it incorrect.
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Which of the following nursing actions would be MOST appropriate?
- A. Determine daily weights and evaluate weight loss.
- B. Evaluate infant's ability to take in fluids.
- C. Place a full bottle of Pedi-Lyte at the bedside.
- D. Start an intravenous infusion.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later