Nokea
The nurse is teaching the parents of a client with iron deficiency anemia about administering a liquid oral iron supplement. Which statement by the parents indicates that teaching was successful?
- A. We will give the iron through a straw.
- B. The iron should be given just before breakfast.
- C. We will give it with food to decrease stomach upset.
- D. We will mix the iron with a milkshake so it will taste better.
Correct Answer: A
Rationale: Using a straw minimizes tooth staining from liquid iron. Iron is best absorbed on an empty stomach, and milk can decrease absorption.
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The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is:
- A. Deviated to the left.
- B. Firm and in the midline.
- C. Boggy.
- D. Two finger breadths below the umbilicus.
Correct Answer: B
Rationale: A firm and midline fundus indicates effective uterine contraction, showing Pitocin is working to prevent postpartum hemorrhage.
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
- A. I do not need to limit my time in public places.'
- B. I may share food from serving dishes with others at a restaurant.'
- C. I may use public restrooms.'
- D. I may donate blood.'
Correct Answer: D
Rationale: AIDS patients cannot donate blood due to HIV transmission risk. Public activities and restrooms pose minimal risk, and sharing serving dishes is safe if not directly contaminated.
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
- A. Right ventricular hypertrophy
- B. Cardiac dysrhythmia
- C. Left ventricular hypertrophy
- D. Hyperkalemia
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
- A. Inspection, auscultation, palpation
- B. Auscultation, palpation, inspection
- C. Palpation, inspection, auscultation
- D. Inspection, palpation, auscultation
Correct Answer: A
Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
- A. My skin is always so dry.
- B. I often use laxatives.
- C. I have always liked to drink a lot of ice tea.
- D. I sometimes have a problem with dribbling urine.
Correct Answer: B
Rationale: Frequent laxative use can lead to dehydration and electrolyte imbalances due to excessive fluid and electrolyte loss through diarrhea.