Nokea
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: A
Rationale: The correct answer is A: Shrimp and tomatoes. Shrimp is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Tomatoes are rich in Vitamin C, which helps enhance iron absorption. Cheese, bananas, lobster, squash, lamb, and peaches do not provide significant amounts of iron essential for an anemic client. The combination of shrimp and tomatoes offers a balanced approach to increase iron levels effectively.
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A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?
- A. Infection
- B. Risk for infection
- C. Impaired skin integrity
- D. Staphylococcal leg infection
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate.
Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity.
Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: The correct answer is C: Restricting sodium. In hyperparathyroidism, there is an excess of parathyroid hormone leading to increased calcium levels. Sodium can worsen calcium excretion, exacerbating the condition. Restricting sodium can help reduce calcium loss.
A: Restricting fluids is not necessary unless the client has kidney issues.
B: Forcing fluids may not be beneficial and can lead to fluid overload.
D: Restricting potassium is not typically necessary unless the client has kidney issues.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.
A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
- A. Wait and change the dressing at 1800 as ordered. NursingStoreRN
- B. Revise the plan of care and change the dressing now.
- C. Reassess the dressing and the wound in 2 hours.
- D. Discontinue the plan of care for wound care.
Correct Answer: B
Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.