Nokea
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
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Which of the following beverages is most appropriate for a client with renal failure?
- A. Prune juice
- B. Grape juice
- C. Apple juice
- D. Apricot juice
Correct Answer: C
Rationale: Apple juice is most appropriate for a client with renalrape juice has a lower potassium content, which is crucial for renal failure patients who need to limit potassium intake. Prune, grape, and apricot juices are high in potassium, which can be harmful in renal failure.
The health care provider (HCP) provides education to an adult client about an upcoming surgical procedure. The client states, 'I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy.' What action should the nurse take?
- A. Ask the client's family member to sign the consent form
- B. Inform the client that the HCP can discuss all questions after surgery
- C. Provide the client with educational materials about low-fat diet options
- D. Reinforce education about the procedure using a visual aid
Correct Answer: C
Rationale: Providing dietary education addresses the client's question directly. Family consent is inappropriate, postponing discussion delays clarification, and procedure education doesn't address diet.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.
The home health nurse is reviewing current medications with a client who has hypertension. Which of the following statements by the client would require follow-up?
- A. I take omeprazole daily to prevent heartburn.
- B. I regularly take ibuprofen for chronic low back pain.
- C. I occasionally take docusate sodium for constipation.
- D. I take hydrochlorothiazide daily to lower my blood pressure.
Correct Answer: B
Rationale: Ibuprofen can reduce the efficacy of antihypertensives and cause fluid retention, worsening hypertension. Omeprazole , docusate , and hydrochlorothiazide are unlikely to interfere with hypertension management.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.