Nokea
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
- A. Fruits
- B. Salt
- C. Pepper
- D. Ketchup
Correct Answer: A
Rationale: Raw fruits may harbor bacteria, posing an infection risk for a neutropenic client on a minimal-bacteria diet.
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A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
- A. Apply the AED pads and deliver a shock.
- B. Wipe the chest dry with an available cloth or towel.
- C. Continue CPR because a client who is wet cannot receive a shock.
- D. Wipe the chest with an alcohol hand wipe to speed the evaporation of the water.
Correct Answer: B
Rationale: Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?
- A. Limited adduction of the right leg.
- B. Uneven gluteal fold and thigh creases.
- C. Increase in length of the right limb.
- D. Internal rotation of the right leg.
Correct Answer: B
Rationale: folds and creases will be longer and deeper on affected side
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
- A. TB skin test
- B. Rubella vaccine
- C. ELISA test
- D. Chest x-ray
Correct Answer: B
Rationale: The rubella vaccine is contraindicated in clients with egg allergies, as it may be grown in egg-based cultures.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns