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Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: High-fiber foods like oatmeal, raisins, and fruit with skin reduce colorectal cancer risk by promoting gut health.
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A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
- A. Painful areas should be rubbed gently until the pain subsides.
- B. Wearing gloves when handling cold items guards against painful spasms.
- C. Return appointments will be needed for IV pain medication.
- D. Enrolling in a pain clinic can provide pain relief alternatives.
Correct Answer: B
Rationale: Wearing gloves prevents cold-induced spasms, reducing pain in Raynaud's disease.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.
A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient's laboratory values should the nurse review?
- A. Blood pH level
- B. Hematocrit
- C. White blood cell (WBC) count
- D. Platelet count
Correct Answer: C
Rationale: WBC count indicates infection, relevant to purulent drainage in a burn wound.
The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform immediately?
- A. Maintain elevated positioning of the dependent joints on the affected side.
- B. Verify prescribed laboratory tests include prothrombin time and platelet count.
- C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- D. Administer aspirin to prevent further clot formation and platelet clumping.
Correct Answer: C
Rationale: Symptoms suggestive of a stroke require immediate initiation of IV access and evaluation for fibrinolytic therapy to restore cerebral blood flow.
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient's response to treatment?
- A. Urinary output.
- B. Skin elasticity.
- C. Pain scale.
- D. Lung sounds.
- E. Oxygen saturation.
Correct Answer: A,D,E
Rationale: Assessing urinary output, lung sounds, and oxygen saturation evaluates furosemide's effectiveness in reducing fluid overload and improving respiratory status.