Nokea
Which meal selection is most appropriate for a patient with iron deficiency anemia?
- A. Roast turkey,gelatin,green beans
- B. Chicken salad, sandwich,coleslaw,French fries
- C. Egg salad on wheat bread,carrot sticks ,spinach and kale salad
- D. Pork chop,mashed potatoes,green peas
Correct Answer: C
Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.
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The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. The water seal chamber is bubbling continuously.
- B. The drainage system is positioned below the client’s chest.
- C. The chest tube is taped securely to the chest.
- D. The client is lying on the affected side.
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
- A. Place a tongue blade in the child's mouth.
- B. Restrain the child so he will not injure himself.
- C. Go to the nurses station and call the physician.
- D. Move furniture out of the way and place a blanket under his head.
Correct Answer: D
Rationale: The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. Restraining the child's movements could cause constrictive injury. Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. The nurse should provide safety for the child by moving objects and protecting the head.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
Which of the following should be included in discharge teaching for a client with hepatitis C?
- A. He should take aspirin as needed for muscle and joint pain.
- B. He may become a blood donor when his liver enzymes return to normal.
- C. He should avoid alcoholic beverages during his recovery period.
- D. He should use disposable dishes for eating and drinking.
Correct Answer: C
Rationale: Alcohol should be avoided as it is detoxified by the liver, which is compromised in hepatitis C. Aspirin is hepatotoxic, blood donation is not allowed, and hepatitis C is not spread orally.
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
- A. Reclining to control bleeding
- B. Any position in which the client is comfortable
- C. Side-lying, either left or right
- D. Sitting with head support
Correct Answer: D
Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.