Nokea
Which food is a reliable source of B12 for a pregnant vegan client?
- A. Soybeans
- B. Algae
- C. Fortified soy milk
- D. Sea vegetables
Correct Answer: C
Rationale: Fortified soy milk is a reliable source of vitamin B12 for pregnant vegan clients as it is usually enriched with this vitamin. The other options, while nutritious, are not reliable sources of B12 for vegans. Soybeans may not provide enough B12, algae contains B12 analogs that the human body cannot utilize, and the B12 content in sea vegetables can fluctuate, potentially not providing the necessary daily intake.
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In conducting a cleansing enema, how does the nurse position the client?
- A. Right lateral position
- B. Left lateral position
- C. Right Sim's position
- D. Left Sim's position
Correct Answer: B
Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.
Why is a pulse oximeter attached to Mr. Dizon's finger?
- A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
- B. To check the level of the patient's tissue perfusion
- C. To measure the effectiveness of the patient's anti-hypertensive medications
- D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop
Correct Answer: D
Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.
What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?
- A. Avoid foods such as smoked meats and frozen dinners.
- B. Select foods with less than 4g of sodium as indicated on food labels.
- C. Use soy sauce for flavoring foods instead of table salt.
- D. Processed and prepared foods are typically low in sodium.
Correct Answer: A
Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.
Where should a nurse auscultate the apex beat?
- A. At the fifth intercostal space, along the midclavicular line
- B. At the mid-sternum
- C. 2 inches to the left of the lower end of the sternum
- D. 1 inch to the left of the xiphoid process
Correct Answer: A
Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.
In which of the following conditions does a person need to sit, stand, or use multiple pillows when lying down?
- A. Orthopnea
- B. Dyspnea
- C. Eupnea
- D. Apnea
Correct Answer: A
Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.