Nokea
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a soft diet with increased intake of milk and milk products.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a bland diet and avoid spicy foods.
- D. Eat a high fiber diet and increase fluid intake.
Correct Answer: D
Rationale: A high-fiber diet with increased fluids promotes bowel regularity, reducing diverticulosis complications.
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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Joint pain.
- B. Hematuria.
- C. Muscle atrophy.
- D. Low grade fever.
Correct Answer: B
Rationale: Hematuria indicates potential lupus nephritis, a serious renal complication requiring urgent evaluation.
Imaging Studies
Day 1, 1100
X-ray of right foot erosion of first metatarsal joint and preservation of joint space consistent with gout
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks
Select the 3 dietary choices that are not part of the recommended diet gout.
- A. Shrimp
- B. Sardines
- C. Quinoa
- D. Oranges
- E. Oatmeal
- F. Spinach
- G. Liver
Correct Answer: A,B,G
Rationale: Shrimp , sardines , and liver are high in purines, which increase uric acid levels and should be avoided in gout management.
The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
- A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
- B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
- C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground
- D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
Correct Answer: A,B,C,D
Rationale: Prioritization is based on the urgency and potential life-threatening nature of the conditions. The asthma attack is the highest priority due to potential airway compromise. Hypoglycemia is next due to the risk of neurological complications. Bleeding lacerations pose a risk of infection and blood loss, and the incontinent episode is primarily psychosocial, making it the lowest priority.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
- A. Remove the ink marks of the portal after each radiation treatment.
- B. Protect the skin of the radiation portal site from sunlight exposure.
- C. Apply moisture lotions daily to the radiation portal site.
- D. Avoid washing the skin inside the radiation portal site.
Correct Answer: B
Rationale: Protecting the portal site from sunlight prevents exacerbated skin reactions during radiation therapy.