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The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.
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A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of body fluids
- D. Changes in color vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.
A client with heart failure has a left ventricular ejection fraction of 38%. When educating the client about managing the condition, which of the following advice should the nurse include? Select all that apply.
- A. The client should take frequent rest periods.
- B. The client should avoid strenuous activities.
- C. The client should stop all exercises.
- D. The client should stop smoking.
- E. The client should limit alcohol intake to 2 to 3 drinks daily.
Correct Answer: A,B,D
Rationale: Rest periods (A), avoiding strenuous activities (B), and stopping smoking (D) manage heart failure. All exercise (C) is not stopped; moderate activity is encouraged. Alcohol should be minimal, not 2-3 drinks (E).
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.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.
According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):
- A. safety and security
- B. esteem
- C. physiological
- D. love and belonging
- E. self-actualization
Correct Answer: C,A,D,B,E
Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).