Nokea
The nurse recognizes that if eaten by a client, which food can alter results when stool is checked for occult blood?
- A. potatoes
- B. dairy products
- C. raw fruits
- D. beef
Correct Answer: D
Rationale: Beef contains heme, which can cause a false-positive result in a fecal occult blood test. Other foods listed do not typically interfere.
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An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is
- A. call the nursing assistant out of the room and speak with him about the incident.
- B. apologize to the patient and assign another nursing assistant to that room.
- C. report the nursing assistant to the nursing manager for poor patient care.
- D. write an incident report and give a copy to the nursing assistant and nurse manager.
Correct Answer: A
Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.
A student nurse is developing a care plan for a 23-year-old woman with Meniere's disease. Which of the following would NOT be an expected intervention?
- A. administer narcotic pain medication PRN as ordered
- B. refer client to dietician to plan meals with reduced sodium levels
- C. assist client out of bed to shower and to toilet
- D. encourage client to eat several, similarly sized meals throughout the day
Correct Answer: A
Rationale: Meniere’s disease causes vertigo and hearing loss, not typically requiring narcotic pain medication. Low-sodium diets, assistance with mobility, and balanced meals help manage symptoms.
The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
- A. Pressure from the fingers and hands to stimulate the energy points in the body
- B. Oils extracted from plants and herbs
- C. Needles to stimulate certain points on the body to treat pain
- D. Manipulation of the skeletal muscles to relieve stress and pain
Correct Answer: C
Rationale: Acupuncture uses needles, which pose an infection risk in immunocompromised AIDS patients, requiring further discussion.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
A client receiving high doses of hydromorphone (Dilaudid®) develops acute respiratory depression with a drop in blood pressure. Which of the following treatments is most indicated?
- A. Naloxone
- B. Naproxen
- C. Flumazenil
- D. Nortriptyline
Correct Answer: A
Rationale: Naloxone (A) reverses opioid-induced respiratory depression. Naproxen (B), flumazenil (C), and nortriptyline (D) are not appropriate.