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The nurse is monitoring fetal heart rate (FHR) on a laboring client. Which finding should be reported to the health care provider?
- A. FHR of 154 bpm with moderate variability
- B. FHR of 114 bpm with moderate variability
- C. FHR of 170 bpm lasting more than 10 minutes
- D. FHR of 156 bpm with minimal variability in a premature infant
Correct Answer: C
Rationale: FHR of 170 bpm for over 10 minutes indicates tachycardia, requiring immediate reporting. Other findings are within normal or less urgent ranges.
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A client has a history of urolithiasis related to hyperuricemia. To prevent the formation of future stones, the nurse instructs the client to avoid which food?
- A. Liver
- B. Carrots
- C. White rice
- D. Skim milk
Correct Answer: A
Rationale: Urolithiasis related to hyperuricemia involves high uric acid levels, and foods high in purines, such as liver, should be avoided because they increase uric acid production. Carrots, white rice, and skim milk are low in purines and safe for this client.
A client with a colostomy complains to the nurse of appliance odor. The nurse recommends that the client take in which deodorizing foods?
- A. Eggs
- B. Yogurt
- C. Cucumbers
- D. Mushrooms
Correct Answer: B
Rationale: Foods that help eliminate odor with a colostomy include yogurt, buttermilk, cranberry juice, and parsley. Foods that cause odor are many and include alcohol, beans, turnips, radishes, asparagus, onions, cucumbers, mushrooms, cabbage, eggs, and fish.
A nursing instructor asks a student to identify risk factors for and methods of preventing prostate cancer. Which statement by the student indicates the need for further teaching?
- A. Smoking increases the risk for this type of cancer.'
- B. A high-fat diet will assist in preventing this type of cancer.'
- C. A history of a sexually transmitted infection is a risk for this disease.'
- D. Men more than 50 years old should be monitored with a yearly digital rectal exam.'
Correct Answer: B
Rationale: Smoking, history of a sexually transmitted infection, and yearly digital examinations are accurate statements regarding the risks and prevention measures related to this type of cancer. Prostate cancer is a slow-growing malignancy of the prostate gland. A high intake of dietary fat is a risk factor for prostate cancer.
The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care?
- A. Assist the client from the affected side.
- B. Place personal items directly in front of the client.
- C. Discourage the client from scanning the environment.
- D. Assist the client with grooming the unaffected side first.
Correct Answer: A
Rationale: Unilateral neglect involves a lack of awareness of the affected side. Assisting from the affected side helps focus the client's attention on it, promoting awareness. Initially, items are placed on the unaffected side, but gradually shifted. Scanning the environment is encouraged, and grooming the affected side first aids awareness.
The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first?
- A. Structure menus for adherence to diet.
- B. Teach with videotapes showing insulin administration to ensure competence.
- C. Encourage dependence on others to prepare the client for the chronicity of the disease.
- D. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment.
Correct Answer: D
Rationale: Assessing the client's ability to read syringe and glucose monitor markings is the first step, ensuring they can manage self-care. Structuring menus or teaching with videos assumes capability, and encouraging dependence is inappropriate.