Nokea
The nurse is providing dietary education to a client with renal failure who is receiving hemodialysis. The nurse determines that the teaching has been effective when the client selects which items from the menu?
- A. Blueberries, cream of wheat, coffee
- B. Bacon, banana, orange juice
- C. Sausage, eggs, tomato juice
- D. Cured pork, grits, kiwi
Correct Answer: A
Rationale: Blueberries and cream of wheat are low in potassium and phosphorus, suitable for renal failure. The other options contain high-potassium or high-phosphorus foods (e.g., banana, orange juice, tomato juice).
You may also like to solve these questions
The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?
- A. Heart rate change from 80 to 125 bpm
- B. Blood pressure change from 125/90 to 119/82 mmHg
- C. A decrease in respiratory rate from 22 to 16 breaths per minute
- D. Saturation of one peri-pad since delivery
Correct Answer: A
Rationale: Tachycardia (heart rate increase to 125 bpm) is an early sign of postpartum hemorrhage due to compensatory response to blood loss.
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
- A. Stop! You will kill your baby.
- B. That is a nice, tight swaddle. It will help soothe your new baby.
- C. May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
- D. Swaddling is not allowed for these babies; please stop.
Correct Answer: C
Rationale: This statement educates the parent gently, explaining the risk to the omphalocele without alarming them.
The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as
- A. obsessive desire for the euphoric effects of a drug
- B. a need for a drug to avoid physical withdrawal symptoms
- C. severe effects that may be life-threatening
- D. unpleasant symptoms related to the absence of a drug
Correct Answer: B
Rationale: Physical dependence is defined as needing a drug to avoid withdrawal symptoms.
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
- A. morphine sulfate
- B. adenosine
- C. diltiazem
- D. atropine sulfate
Correct Answer: A
Rationale: Morphine sulfate is used to manage tet spells by reducing oxygen demand and relaxing the child.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 6 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse transfused the prescribed fresh frozen plasma. Click to specify which assessment data is necessary after the transfusion of FFP.
- A. international normalized ratio
- B. activated thromboplastin time (aPTT)
- C. hematocrit
- D. vital signs
Correct Answer: A, D
Rationale: INR and vital signs are critical to assess the effectiveness of FFP in correcting coagulopathy and monitoring for transfusion reactions.