Nokea
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.
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A client must take oral potassium supplements every day. The nurse explains to the client that the potassium supplements
- A. need to be stored in the refrigerator.
- B. should only be taken in the evening before bed.
- C. should be diluted in a glass of cold water or juice.
- D. need to be taken on an empty stomach.
Correct Answer: C
Rationale: Oral potassium supplements should be diluted in water or juice to reduce gastric irritation and improve absorption.
The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq. The nurse should administer the medication:
- A. Slow, continuous IV push over 10 minutes
- B. Continuous infusion over 30 minutes
- C. Controlled infusion over 5 hours
- D. Continuous infusion over 24 hours
Correct Answer: C
Rationale: Potassium chloride should be administered slowly (e.g., over 5 hours for 50 mEq) to prevent cardiac complications, as rapid infusion can cause hyperkalemia.
Which statement is incorrect regarding the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987 (OBRA '87)?
- A. the right to be free of unnecessary chemical restraints
- B. the right to choose a personal physician
- C. the right to access medical records
- D. the right to organize hospital personnel within a union
Correct Answer: D
Rationale: OBRA '87 does not include the right to organize hospital personnel into a union. Other rights are part of the act.
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
- A. There was damage to the hypothalamus.
- B. He has an infection from the abrasions to the head and face.
- C. He will require a cooling blanket to decrease the temperature.
- D. There was damage to the frontal lobe of the brain.
Correct Answer: B
Rationale: Infection from abrasions is the most likely cause of fever post-accident, as it's a common complication.
What clinical manifestation is most indicative of possible carbon monoxide poisoning?
- A. Pulse oximetry reading of 80%
- B. Expiratory stridor and nasal flaring
- C. Cherry red color to the mucous membranes
- D. Presence of carbonaceous particles in the sputum
Correct Answer: C
Rationale: Cherry red mucous membranes are a hallmark of carbon monoxide poisoning due to carboxyhemoglobin formation, which gives tissues a bright red appearance.