Nokea
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
- A. High in carbohydrates and proteins
- B. Low in carbohydrates and proteins
- C. High in carbohydrates, low in proteins
- D. Low in carbohydrates, high in proteins
Correct Answer: A
Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.
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Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.
The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed
- A. removing the protective gown with the contaminated side facing away from the body
- B. placing a surgical mask on the client before transport outside of the client's room
- C. removing the N95 respirator mask while inside the client's room
- D. keeping the door to the client's room closed at all times
Correct Answer: C
Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B, D) follow correct infection control protocols.
An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?
- A. Lower extremity pulses, paresthesias, and pain
- B. The presence of bowel sounds
- C. Radial pulse, sensation, and movement of the arms
- D. Palpation of the bladder
Correct Answer: A
Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.
The nurse is providing home care for a client who is visually impaired. What safety precaution is most appropriate for this client?
- A. Remove scatter rugs.
- B. Have hand rails in the bathroom.
- C. Have side rails up whenever the client is in bed.
- D. Have a bell to call for help.
Correct Answer: A
Rationale: Removing scatter rugs prevents tripping, the most effective safety measure for a visually impaired client at home.
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.
- A. Elevate the right leg on two pillows.'
- B. Measure client for compression stockings.'
- C. Please let me know what the urine looks like.'
- D. Tell me what the client eats at lunch.'
- E. Verify wrist restraints are on correctly.'
Correct Answer: A,C,D
Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.