Nokea
The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Tofu
- C. Almonds
- D. Prunes
- E. Baked fish
- F. Grapefruit
Correct Answer: A,B,C,D,F
Rationale: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
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The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). To prevent complications during and after the procedure, the nurse should assess the client's
- A. sensation in the lower extremities
- B. dentition
- C. grip strength
- D. peripheral vision
Correct Answer: B
Rationale: Assessing dentition is critical before ECT to identify loose teeth or dental appliances that could pose an airway risk during induced seizures. Sensation, grip strength, and peripheral vision are not directly related to ECT complications.
The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take?
- A. Place a box of disposable respirators inside the client's room.
- B. Remove alcohol-based sanitizers from the client's room.
- C. Assign the client to a private room with a positive airflow.
- D. Remove the portable fan from the client's bedside table.
Correct Answer: D
Rationale: Removing the portable fan prevents the spread of airborne Mycobacterium tuberculosis. A negative airflow room is required, and respirators should be stored outside the room.
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.