Nokea
The nurse is teaching a client with a new colostomy about dietary management. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Eggs.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, eggs, or beans, which may increase gas.
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The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
- A. Encourage early ambulation.
- B. Apply cold compresses to the affected leg.
- C. Elevate the affected leg.
- D. Massage the affected leg.
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
- A. Use the inhaler daily to prevent attacks.
- B. Rinse the mouth after each use.
- C. Use the inhaler during an acute attack.
- D. Stop the inhaler if heart palpitations occur.
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
- A. Spina bifida cystica.
- B. Spina bifida occulta.
- C. Meningocele.
- D. Myelomeningocele.
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
- A. Chest pain radiating to the left arm.
- B. Bilateral leg swelling.
- C. Fever.
- D. Dry cough.
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.