Nokea
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
- A. Safflower oil
- B. Sunflower oil
- C. Coconut oil
- D. Canola oil
Correct Answer: C
Rationale: Coconut oil is high in saturated fats, which raise LDL cholesterol, making it unsuitable for a low-cholesterol diet.
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Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?
- A. It will facilitate catheter insertion.
- B. It will make the client more comfortable during the insertion.
- C. It will prevent the occurrence of ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: The Trendelenburg position increases venous filling in the upper body, making the subclavian or jugular veins easier to access for catheter insertion.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.
- B. She sleeps quite a bit of the time.
- C. Her gums look too big for her teeth.
- D. She has gained about 10 pounds in the last six months.
Correct Answer: C
Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.
The nurse who is caring for a client with cancer notes a WBC of 500 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every 4 hours because of risk for hypothermia
- B. Instruct the client to avoid large crowds and people who are sick
- C. Instruct in the use of a soft toothbrush
- D. Assess for hematuria
Correct Answer: B
Rationale: A WBC of 500 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people is critical to prevent infections. The other interventions are less specific.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.