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The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?
- A. Cheeseburger with tomato and onion.
- B. Spaghetti with meat sauce and green beans.
- C. Tuna fish sandwich with orange juice.
- D. Grilled cheese sandwich and chocolate pudding.
Correct Answer: B
Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.
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Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
- A. I should brush my teeth regularly.
- B. I should report any skin rashes to my doctor.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
A 46-year-old man with newly diagnosed diabetes mellitus.
Which of the following responses by the nurse is BEST?
- A. It is best to buy new shoes in the morning.'
- B. Have each foot measured every time you buy new shoes.'
- C. Buy shoes one half size larger than your foot size so the fit is roomy.'
- D. Buy vinyl shoes because they won't lose their shape easily.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should buy shoes in the afternoon when feet are larger than in the morning (2) correct-feet enlarge with age, don't break in shoes all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they 'breathe', vinyl could cause foot to perspire and aggravate fungal infections
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.
The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.