Nokea
Which instruction should the nurse include in the teaching plan for a client taking iron supplements to correct iron deficiency anemia?
- A. Eat a low-fiber diet.
- B. Limit the intake of fluids.
- C. Limit the intake of meat, fish, and poultry.
- D. Avoid taking the iron supplements with milk or antacids.
Correct Answer: D
Rationale: The client should avoid taking the iron supplements with milk or antacids because these items decrease the absorption of iron. The client should also avoid taking the iron with food, if possible. Finally, the client should take in sufficient fiber and fluids to prevent constipation as a side effect of iron therapy. The client should increase the intake of natural sources of iron, such as meats, fish, and poultry.
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A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge teaching plan for the client and identifies which intervention as a priority?
- A. Exercise routines
- B. Controlling dietary intake
- C. Keeping follow-up appointments
- D. Monitoring for signs/symptoms of dehydration
Correct Answer: D
Rationale: Monitoring for dehydration is the priority for HHS, as it can progress rapidly and is life-threatening. Exercise, diet, and follow-up are important but secondary to preventing dehydration-related complications.
After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?
- A. Tap water
- B. Sterile water
- C. Full-strength hydrogen peroxide
- D. Half-strength hydrogen peroxide
Correct Answer: B
Rationale: After cleft lip repair, the site is cleansed with sterile water using a cotton swab after feeding and as prescribed. Agency procedure should also be followed. The parents should be instructed to use a rolling motion starting at the suture line and rolling out. Tap water is not a sterile solution. Hydrogen peroxide may disrupt the integrity of the site.
A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products?
- A. Milk
- B. Yogurt
- C. Spinach, chocolate, and tea
- D. Sardines, herring, and organ meats
Correct Answer: D
Rationale: The client diagnosed with a uric acid stone should limit the intake of foods that are high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. Foods with moderate levels of purines, such as red and white meats and some seafood, are also limited. Milk, yogurt, spinach, chocolate, and tea are recommended dietary changes to prevent calculi that are composed of calcium phosphate or calcium oxalate.
The nurse is teaching a client with acute kidney injury to include proteins in the diet that are considered high quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality?
- A. Fish
- B. Eggs
- C. Chicken
- D. Broccoli
Correct Answer: D
Rationale: High-quality or complete proteins, which contain essential amino acids, come from animal sources like fish, eggs, and chicken. Broccoli, a plant-based source, provides low-quality or incomplete proteins, indicating the client's misunderstanding.
The nurse is caring for a client who is 38 weeks pregnant and plans to breastfeed. This is the client's first child, and she expresses concern about lactation. The nurse tells the client that which measures stimulate lactation? Select all that apply.
- A. breast massage
- B. frequent breastfeeding
- C. pumping breasts between feedings
- D. vigorous exercise one week after birth
- E. applying cold compresses to the breasts
Correct Answer: A,B,C
Rationale: Breast massage, frequent breastfeeding, and pumping stimulate milk production. Exercise and cold compresses do not.