Nokea
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Almond butter
- C. Grilled chicken
- D. Apricots
- E. Baked fish
- F. Seafood salad
Correct Answer: A,B,D
Rationale: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.
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The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.
The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply.
- A. Apply gloves for this procedure
- B. Have the client wash their hands with soap and water prior to blood collection
- C. Collect the second blood drop on the test strip
- D. Prick the central part of the finger for the sample
- E. Clean and disinfect the glucometer in between uses
Correct Answer: A,B,C,E
Rationale: Gloves protect against blood exposure, hand washing ensures a clean sample, the second drop avoids contamination, and disinfecting the glucometer prevents infection. Pricking the central finger part is less preferred than the side.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.