Nokea
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.
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The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein?
- A. 10-30 degrees
- B. 30-45 degrees
- C. 45-90 degrees
- D. 45-60 degrees
Correct Answer: A
Rationale: A 10-30 degree angle is optimal for PVAD insertion to enter the vein without piercing through it. Higher angles increase the risk of vein perforation or improper placement.
The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.
The nurse is preparing a staff education program about physiological responses of stress. Which of the following is a physiological alteration that can occur with stress?
- A. Decreased visual acuity
- B. Increased peristalsis
- C. Decreased glucocorticoids
- D. Hyperglycemia
Correct Answer: D
Rationale: Stress triggers hyperglycemia via cortisol release. Visual acuity and peristalsis are not directly affected, and glucocorticoids increase, not decrease.
The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.