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Which group of food selections would be appropriate for a client on a full liquid diet 3 days after bariatric surgery?
- A. Apple juice, mashed potatoes, and chocolate pudding
- B. Chicken broth, low-fat cheese omelet, and strawberry ice cream
- C. Creamy wheat cereal, blended cream of chicken soup, and a protein shake
- D. Low-fat vanilla yogurt, smooth peanut butter, and vegetable juice
Correct Answer: C
Rationale: Creamy wheat cereal, blended soup, and protein shakes are full liquids suitable post-bariatric surgery. The other options include solid foods.
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While caring for a client with a pulmonary embolus, the nurse notes several petechiae on his chest and abdomen. Which action should the nurse take first?
- A. Apply ice packs to the area.
- B. Record the finding in the client's chart.
- C. Report the finding to the physician.
- D. Monitor the finding.
Correct Answer: C
Rationale: Petechiae may indicate a coagulopathy or emboli-related complication, requiring prompt reporting to the physician for further evaluation. Recording and monitoring are secondary, and ice packs are inappropriate.
The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.
- A. 900 mL
Correct Answer: A
Rationale: Irrigation input = 175 mL/hr × 8 hr = 1400 mL. Total output = 2300 mL. Net urine output = 2300 mL - 1400 mL = 900 mL.
Clients taking which of the following drugs are at risk for depression?
- A. Steroids
- B. Diuretics
- C. Folic acid
- D. Aspirin
Correct Answer: A
Rationale: Steroids. Corticosteroids can cause depression as a side effect, which may persist even after discontinuation.
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?
- A. I usually take naproxen for pain twice a week
- B. I received my annual influenza vaccine injection 3 weeks ago.
- C. I received a negative test result for my tuberculin skin test one week ago.
- D. I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.
Correct Answer: D
Rationale: Adalimumab, an immunosuppressant, increases infection risk. Starting antibiotics for an active infection requires follow-up to ensure the infection is resolved before initiating adalimumab. The other statements are not concerning.