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The nurse is reinforcing information on dietary management to a group of clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?
- A. Baked tilapia with tomato salsa, steamed white rice
- B. Black bean chili with brown rice, mixed greens salad
- C. Grilled chicken breast with baked French fries
- D. Hamburger on a whole wheat bun with lettuce and tomato
Correct Answer: B
Rationale: Baked bean chili with brown rice and salad provides fiber, lean protein, and vegetables, balancing blood sugar. Fries and hamburger buns are higher in simple carbs, less ideal for diabetes control.
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The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client?
- A. Frequent hand hygiene
- B. No artificial nails
- C. Use of chlorhexidine bath wipes
- D. Wearing personal protective equipment
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective intervention to prevent infection in central venous access, reducing pathogen transmission. No artificial nails and chlorhexidine wipes are supportive, but hand hygiene is primary. PPE is situational.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
The nurse is assessing for jaundice in a client who has dark skin. What is the best way to do this?
- A. Ask the client if his/her stool has changed color
- B. Look at the client's sclera
- C. Pinch the nail beds and observe the color
- D. Look at the client's fingers
Correct Answer: B
Rationale: The sclera (white of the eyes) reliably shows yellowing in jaundice, even in dark skin, unlike stool color, nail beds, or fingers, which are less specific.
The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.