Nokea
The nurse is evaluating a weight-reduction plan designed for an obese client. Which statement by the client indicates the need for further teaching?
- A. It is so difficult to find food exchanges that taste good and fill me up.
- B. This diet doesn't let me go out for lunch with my friends at work anymore.
- C. I wish my mother could have seen me lose the 60 pounds in the last 9 months.
- D. My wife was kidding me the other night about my being a whole new husband.
Correct Answer: B
Rationale: Option 2 indicates that the client may be having difficulty in making appropriate dietary choices when going out for lunch or that he may perceive that his coworkers are uncomfortable with his need to eat differently. A sense of not fitting in can leave the obese individual isolated and therefore make it more difficult for him to maintain his diet at work. In the absence of other data, option 1 is a normal response to the changes in eating habits. Options 3 and 4 are responses indicating a positive perception of self; that is, another person has recognized these changes, and the client wishes to have been able to share these changes with his mother.
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The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
- A. Fish
- B. Dog
- C. Cat
- D. Bird
Correct Answer: A
Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
- A. Obtain the 12-lead ECG.
- B. Draw the blood specimens.
- C. Apply the oxygen to the client.
- D. Schedule the chest x-ray study.
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
The nurse is caring for a client with a nasogastric tube. Which action confirms correct placement?
- A. Check pH of aspirate.
- B. Observe for bubbling in water.
- C. Inject air and auscultate.
- D. Visualize tube in the throat.
Correct Answer: A
Rationale: Checking the pH of aspirate (pH ‰¤ 5.5) confirms the tube is in the stomach, ensuring safe placement.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
- A. Restricting visitors with colds or respiratory infections
- B. Removing all live plants, flowers, and stuffed animals in the client's room
- C. Placing the client on a low-bacteria diet that excludes raw foods and vegetables
- D. Padding the side rails and removing all hazardous and sharp objects from the room
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.