The parents of a child with cystic fibrosis discuss nutritional requirements and the need for vitamin supplements with the nurse. The nurse explains that it is necessary to give daily supplements of vitamins A, D, E, and K because:
- A. Children with cystic fibrosis require vitamin supplements because their metabolism is increased.
- B. Children with cystic fibrosis do not eat a well-balanced diet.
- C. Children with cystic fibrosis do not absorb fat-soluble vitamins.
- D. Children with cystic fibrosis have an increased excretion of water-soluble vitamins.
Correct Answer: C
Rationale: Cystic fibrosis impairs fat absorption, leading to deficiencies in fat-soluble vitamins (A, D, E, K), necessitating supplementation.
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The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with antacids.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping levothyroxine when thyroid levels are normal is incorrect, as hypothyroidism requires lifelong replacement therapy. Options A, B, and C are correct: empty stomach dosing improves absorption, chest pain may indicate overdose, and antacids interfere with absorption.
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.
The nurse is caring for a client receiving chemotherapy.
- A. Which symptom should the nurse report immediately for a client receiving chemotherapy?
- B. Nausea and vomiting.
- C. A temperature of 100.8°F (38.2°C).
- D. Fatigue and weakness.
- E. Alopecia.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
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