Nokea
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Encourage the client to cough and deep breathe every 2 hours
- B. Place the client in contact isolation
- C. Provide a diet high in protein
- D. Institute seizure precautions
Correct Answer: A
Rationale: Encourage the client to cough and deep breathe every 2 hours. Coughing and deep breathing prevent respiratory infections due to shallow respirations.
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The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, HPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?
- A. DTaP
- B. Hepatitis B
- C. Polio
- D. H. Influenza
Correct Answer: A
Rationale: The majority of reactions occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
- A. The nursing assistant washes hands first thing in the morning before giving care to any client and again after all morning care is completed.
- B. The nursing assistant wears gloves during all client contact.
- C. The nursing assistant wears a gown when changing linen soiled with urine and feces.
- D. The nursing assistant changes gloves between clients but does not wash hands if gloves have been worn.
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.