Nokea
The nurse is reviewing recommended dietary modifications with a client with celiac disease. Which of the following menu selections by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Beef barley soup with mixed vegetables and French bread
- B. Corn tortilla tacos with ground beef and cheese
- C. Grilled chicken, baked potato, and strawberry yogurt
- D. Peanut butter and jelly on whole wheat bread and an apple
- E. Rice noodles with chicken and broccoli
Correct Answer: B,C,E
Rationale: Corn tortillas, grilled chicken with potato/yogurt, and rice noodles are gluten-free, suitable for celiac disease. Barley and wheat contain gluten.
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A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.
The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube and a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply.
- A. Administer the scheduled feeding as prescribed.
- B. Discard the aspirated residual in a biohazard container.
- C. Place the client in the high-Fowler position during the feeding.
- D. Flush the nasogastric tube before and after administering the feeding.
- E. Check the pH of the residual and notify the health care provider if the pH is > 5.
Correct Answer: A,C,D
Rationale: A residual of 75 mL is typically acceptable to proceed with feeding. High-Fowler position and flushing are standard. Residual is returned, not discarded, and pH >5 is not concerning.
A nursing diagnosis of 'ineffective airway clearance related to pain' is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?
- A. Administer prescribed analgesic medication for incisional pain
- B. Encourage use of incentive spirometer every 2 hours while awake
- C. Offer an additional pillow to splint the incision while coughing
- D. Promote increased oral fluid intake
Correct Answer: A
Rationale: Pain control is the priority to enable effective coughing and airway clearance.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation
The nurse is assisting with the admission of a client who had a nephrectomy 6 hours ago. The client should be assigned to a semiprivate room with a client who has
- A. a pulmonary embolism, is receiving heparin therapy, and has a decreased platelet count
- B. cellulitis of the leg, is receiving antibiotic therapy, and is reporting loose stools
- C. type 1 diabetes mellitus, a wound on the foot, and an elevated temperature
- D. HIV infection, a decreased CD4+ cell count, and is reporting fatigue
Correct Answer: B
Rationale: The client with cellulitis and loose stools is least likely to pose an infection risk to the post-nephrectomy client, who is at risk for infection due to recent surgery. Other options involve conditions with higher infection risks or bleeding concerns.