Nokea
Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
- A. Egg whites, toast, and coffee.
- B. Bran muffin, mixed fruits, and orange juice.
- C. Granola and grapefruit juice.
- D. Bagel with jelly and skim milk.
Correct Answer: D
Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.
You may also like to solve these questions
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?
- A. Bradycardia
- B. Muscle weakness
- C. Peaked T waves on the ECG
- D. Decreased deep tendon reflexes
Correct Answer: C
Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.
A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?
- A. Hemoglobin
- B. White blood cell count
- C. Serum potassium
- D. Serum creatinine
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.
A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?
- A. Leakage around the catheter insertion site.
- B. Pink-tinged urine in the drainage bag.
- C. Client reports discomfort at the catheter site.
- D. Decreased urine output in the last hour.
Correct Answer: A
Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.
The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer nitroglycerin sublingually as prescribed.
- C. Obtain an electrocardiogram (ECG).
- D. Assess the client's level of consciousness.
Correct Answer: C
Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.
Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?
- A. Transfuse packed red blood cells.
- B. Obtain blood and sputum cultures.
- C. Infuse 1000 ml of normal saline.
- D. Titrate oxygen to keep O2 saturation at 90%.
Correct Answer: A
Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.