Nokea
The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of 95 mg/dL
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.
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A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.
A 32-year-old woman comes into the clinic for a well-woman exam and asks for information on an intrauterine device (IUD) for contraception. The nurse should explain that all of the following are potential risks EXCEPT
- A. stroke.
- B. pelvic infections.
- C. abnormal menstrual bleeding.
- D. ectopic pregnancy.
Correct Answer: A
Rationale: IUD risks include pelvic infections, abnormal bleeding, and ectopic pregnancy. Stroke is not a recognized risk associated with IUD use.
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.
The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be:
- A. Yes, you should be able to swim again, even with the colostomy.'
- B. You should avoid immersing the colostomy in water.'
- C. No, you should avoid getting the colostomy wet.'
- D. Don't worry about that. You will be able to live just like you did before.'
Correct Answer: A
Rationale: Swimming is possible with a colostomy if proper precautions, like a waterproof seal, are used to protect the stoma.