Nokea
A nurse is teaching dietary guidelines to a client who has celiac disease.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
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A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.
- B. I will obtain the client's weight every other day.
- C. I will monitor the client's blood glucose level every eight hours.
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct answer is A because hanging a new bag of TPN and IV tubing every 24 hours helps to prevent bacterial growth and contamination, ensuring the client's safety. TPN solutions are prone to bacterial contamination if left hanging for too long, so changing the bag and tubing every 24 hours is crucial.
Summary of incorrect choices:
B: Obtaining the client's weight every other day is important for monitoring the effectiveness of TPN therapy, but it does not specifically address the procedure for administering TPN.
C: Monitoring the client's blood glucose level every eight hours is essential for managing TPN therapy, but it does not directly relate to the procedure of administering TPN.
D: Increasing the rate of TPN infusion without proper authorization or assessment can lead to serious complications such as hyperglycemia or fluid overload, making this choice incorrect.
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Swelling of the face
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Swelling of the face. This finding could be indicative of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and organ damage. It is crucial to report this to the provider promptly to prevent complications. Bleeding gums (A) are common due to hormonal changes and increased blood flow, not typically a cause for concern. Faintness upon rising (B) is common in pregnancy due to low blood pressure but usually not a significant issue unless severe. Urinary frequency (D) is normal in pregnancy due to the growing uterus pressing on the bladder.
A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
The nurse continues to care for the client.
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums of
money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer. Client states that this person has never told them to do anything: they
just stare and smile.
Day 1, 1015:
Client's erratic behavior continues with loud outbursts. Continues to get out of bed and pace
around the unit. Prescription received to admit client to inpatient mental health unit.
A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.
- A. Encourage the client to avoid napping during the day.
- B. Place the client in a room away from the nurses' station.
- C. Weigh the client each day
- D. Provide the client with high-calorie fluids every hour.
Correct Answer: A,D
Rationale: Anticipated prescriptions include avoiding naps (to regulate sleep) and providing high-calorie fluids (for nutrition). Contraindicated prescriptions include isolating the client (which may worsen agitation) and daily weighing (unnecessary unless monitoring weight gain/loss).
A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.