Nokea
Which group of foods should the nurse recommend for patients 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: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.
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A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for decreased output.
- C. Restrict physical activities.
- D. Report when hematuria becomes pink-tinged.
Correct Answer: B
Rationale: Monitoring urinary output detects complications like obstruction in hydronephrosis or renal calculi.
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.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
- A. Brown, rough, greasy, wart-like papules on the face.
- B. Thick skin plaques topped by silvery white scales.
- C. Requires sunglasses because sunlight hurts eyes.
- D. Tenderness upon palpation and generalized erythema.
Correct Answer: D
Rationale: Tenderness and generalized erythema indicate overexposure to PUVA, signaling potential burns or excessive UV exposure.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation dislodges blood clots, ensuring catheter patency and preventing urinary obstruction.