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The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
- A. Hamburger patty, green beans, French fries, and iced tea
- B. Roast beef sandwich, potato chips, baked beans, and cola
- C. Baked chicken, fruit cup, potato salad, coleslaw,yogurt, and iced tea
- D. Fish sandwich, gelatin with fruit, and coffee
Correct Answer: C
Rationale: Baked chicken fruit potato salad coleslaw and yogurt provide a balanced mix of protein calcium vitamins and fiber meeting pregnancy nutritional needs. The other options are higher in fat or lack key nutrients.
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The nurse is caring for a client with a history of a pulmonary embolism who is receiving Warfarin (Coumadin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Warfarin, an anticoagulant, increases bleeding risk, requiring monitoring for signs like epistaxis or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Serosanguinous
- B. Purulent
- C. Sanguinous
- D. Catarrhal
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.
Which one of the following statements is correct when measuring the client for crutches?
- A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla.
- B. The nurse should measure three inches between the top of the crutch and the axilla.
- C. The client's elbows should be flexed at a 10° angle.
- D. The crutches should be extended 8 to 10 inches from the side of the foot.
Correct Answer: B
Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg.
- B. Cover the bone area with a sterile dressing.
- C. Apply an ACE bandage around the entire lower limb.
- D. Place the client in the prone position.
Correct Answer: B
Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (A) is secondary, an ACE bandage (C) may contaminate the wound, and prone positioning (D) is inappropriate.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.