Nokea
Which diet selection contains the most potassium and should be removed from the tray of the client with renal failure?
- A. Peach
- B. Baked potato
- C. Marshmallows
- D. Bread
Correct Answer: B
Rationale: Baked potatoes are high in potassium, which is restricted in renal failure to prevent hyperkalemia. Peach , marshmallows , and bread have lower potassium content.
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The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 88 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Absence of bowel sounds.
- D. Pain rated as 6 out of 10.
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
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.
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.
A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Her mother is a type I diabetic.
The nurse knows the infant is at GREATest risk for developing
- A. hypovolemia.
- B. hypoglycemia.
- C. hyperglycemia.
- D. cold stress.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice. (1) no change in blood volume for infant of diabetic mother (2) correct-fetus produces increased insulin to match mother's increased glucose level during pregnancy, infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment, increases metabolic rate, infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes, not expected with diabetic mother
The newborn infant of an HIV-positive mother is admitted to the nursery.
- A. What should the nurse include in the plan of care for a newborn of an HIV-positive mother?
- B. Standard precautions.
- C. Test ing for HIV.
- D. Transfer to an acute care nursery facility.
- E. Request AZT from the pharmacy.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.