Nokea
The nurse is teaching a client with chronic kidney disease about dietary restrictions. Which of the following foods should the nurse advise the client to limit?
- A. Fresh strawberries.
- B. Baked chicken.
- C. Potato chips.
- D. Brown rice.
Correct Answer: C
Rationale: Potato chips are high in sodium and potassium, which must be limited in chronic kidney disease to prevent fluid retention and hyperkalemia. Options A, B, and D are more suitable: strawberries are low-potassium, chicken is protein-rich, and brown rice is acceptable in moderation.
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The nurse is to start oxygen therapy via nasal cannula. Which action is correct?
- A. Set the oxygen at 12 L/min.
- B. Lubricate the cannula with petrolatum before inserting.
- C. Give 100% oxygen by mask before inserting.
- D. Insert the cannula 1 cm into the nostrils.
Correct Answer: D
Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
- A. Consider a liquid supplement to increase calories
- B. Discuss consequences of an unbalanced diet with the child
- C. Provide fruit, vegetable and protein snacks
- D. Encourage the child to keep a daily log of foods eaten
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
- A. Prevent contractures.
- B. Promote flexion of the artificial joint.
- C. Decrease the pain associated with early ambulation.
- D. Alleviate lactic acid production in the leg muscles.
Correct Answer: A
Rationale: A CPM machine prevents contractures by maintaining joint mobility post-knee repair. It aids flexion but primarily prevents stiffness. Pain and lactic acid are secondary concerns.
An infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
- A. Encourage intake of oral fluids to prevent dehydration.
- B. Restrain the child appropriately to maintain the integrity of the IV site.
- C. Place the child on droplet precautions.
- D. Encourage the parents to hold and rock the infant to promote comfort.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluids are usually limited to prevent cerebral edema (2) not a priority (3) correct-to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head