Nokea
The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 72 beats per minute
- B. A hemoglobin level of 12 g/dL
- C. The client reports black, tarry stools
- D. The client reports nausea and vomiting
Correct Answer: C
Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.
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During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?
- A. Breath sounds are auscultated bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88%
- D. Client is unable to speak
Correct Answer: C
Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.
After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?
- A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.
A client who is 2 days postoperative following abdominal surgery is transitioning from a clear liquid diet to a full liquid diet. The nurse should remind the client that which of the following items is included in a full liquid diet?
- A. Creamed peas
- B. Cottage cheese
- C. Chocolate pudding
- D. Applesauce
Correct Answer: C
Rationale: The correct answer is C, chocolate pudding. A full liquid diet consists of smooth, creamy foods like pudding. Creamed peas (choice A) are not typically allowed on a full liquid diet as they may contain solid pieces. Cottage cheese (choice B) and applesauce (choice D) are also not part of a full liquid diet as they are not in liquid form.
A nurse is reinforcing teaching with a client who has Crohn's Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?
- A. Increase your caloric intake by eating foods high in protein.
- B. Include fresh fruits and vegetables at each meal.
- C. Maintain your weight by eating high-fat foods.
- D. Drink whole milk to ensure adequate calcium intake.
Correct Answer: A
Rationale: The correct answer is A. Increasing caloric intake by eating foods high in protein can help Crohn's Disease patients maintain their weight and manage symptoms. Choice B is incorrect because fresh fruits and vegetables may exacerbate symptoms due to their high fiber content. Choice C is incorrect as high-fat foods can be difficult to digest and may worsen symptoms. Choice D is incorrect because whole milk can be problematic for individuals with Crohn's Disease due to its high fat content.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with the client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway in the mouth and suction
- D. Announce a cardiac arrest and assist with intubation
Correct Answer: A
Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.