Nokea
To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?
- A. Sit upright for 30 minutes after meals.
- B. Drink liquids with meals, avoiding caffeine.
- C. Avoid milk and other dairy products.
- D. Decrease the carbohydrate content of meals.
Correct Answer: D
Rationale: Decreasing carbohydrate content helps slow gastric emptying, reducing the risk of dumping syndrome. Sitting upright is helpful but less specific, and drinking liquids with meals can worsen symptoms.
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A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
Which of the following changes are associated with normal aging?
- A. The outer layer of skin is replaced with new cells every 3 days.
- B. Subcutaneous fat and extracellular water decrease.
- C. The dermis becomes highly vascular and assists in the regulation of body temperature.
- D. Collagen becomes elastic and strong.
Correct Answer: B
Rationale: Aging reduces subcutaneous fat and extracellular water, leading to thinner, drier skin. Cell replacement slows, vascularity decreases, and collagen loses elasticity.