Nokea
The nurse is teaching a client with hypothyroidism. The nurse should recommend that the client increase their intake of foods rich in
- A. Fiber.
- B. Saturated fats.
- C. Calcium.
- D. Potassium.
Correct Answer: A
Rationale: Fiber aids digestion, often slowed in hypothyroidism. Saturated fats, calcium, and potassium are not specifically indicated.
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The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
- A. Pain
- B. Anxiety
- C. Depression
- D. Fluid volume deficit
Correct Answer: A
Rationale: Stooped gait, grimacing, and gasping suggest pain, requiring immediate assessment. Anxiety, depression, or fluid deficit are less likely based on these signs.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
The nurse is caring for a client with increased intracranial pressure (ICP). The nurse plans on positioning the client's head of bed at
- A. 25 degrees.
- B. 30-40 degrees.
- C. 10-20 degrees.
- D. 5-10 degrees.
Correct Answer: B
Rationale: A 30-40 degree elevation optimizes cerebral venous drainage, reducing ICP. Lower angles may increase ICP, and 25 degrees is suboptimal.
The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?
- A. A doppler
- B. A surgical vein cut down
- C. A transillumination device
- D. A sonography
Correct Answer: C
Rationale: A transillumination device uses light to visualize veins, aiding IV insertion in clients with dark skin or poor vein visibility. Doppler assesses blood flow, surgical cutdown is invasive, and sonography is not typically used for peripheral IVs.
The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?
- A. Have a designated blood pressure cuff in the client's room.
- B. Remove all gowns and gloves after exiting the client's room.
- C. Clean commonly touched surfaces with warm, soapy water.
- D. Wear a protective gown when transporting the client to other departments.
Correct Answer: A,B
Rationale: A designated BP cuff and removing PPE after exiting prevent varicella spread (airborne and contact). Soapy water is insufficient, and gowns during transport are unnecessary if precautions are followed.