Nokea
The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?
- A. a banana
- B. a bowl of beef broth
- C. a vanilla pudding cup
- D. a cup of strawberries
Correct Answer: A
Rationale: Bananas can cause a cross-reaction in latex-allergic clients due to shared proteins (latex-fruit syndrome). Other items are safe.
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The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.
A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse's teaching regarding radioactive implants?
- A. I won't be able to have visitors while getting radiation therapy.
- B. I will have a urinary catheter while the implant is in place.
- C. I can be up to the bedside commode while the implant is in place.
- D. I won't have any side effects from this type of therapy.
Correct Answer: C
Rationale: Clients with radioactive implants can use the bedside commode if the implant remains secure, indicating understanding of mobility restrictions to minimize radiation exposure.
Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?
- A. I will administer the medication 1-2 inches away from the umbilicus.'
- B. I will administer the medication in the abdomen.'
- C. I will check the PTT before administering the medication.'
- D. I will need to aspirate when I give Heparin.'
Correct Answer: D
Rationale: Aspirating during heparin injection is incorrect, as it increases the risk of hematoma formation in subcutaneous administration.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?
- A. elevated magnesium
- B. lowered magnesium
- C. elevated glucose
- D. lowered glucose
Correct Answer: C
Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.