A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage
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The nurse is caring for a client with a history of rheumatoid arthritis.
- A. Which symptom is expected in a client with rheumatoid arthritis?
- B. Morning stiffness lasting over 30 minutes.
- C. Pain that worsens with activity.
- D. Asymmetrical joint involvement.
- E. Rapid onset of symptoms.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to joint inflammation. Pain improves with activity, joints are symmetrically affected, and onset is gradual.
A mentally retarded, nonverbal, ambulatory client is found sitting on the floor unable to get up. The LPN/LVN notes the client appears to be in great pain, and his right leg is out of alignment. What is the most important action for the nurse to take as the client is readied for ambulance transport?
- A. Give the client pain medication
- B. Immobilize the leg
- C. Gather any medical records that need to accompany the client
- D. Complete the incident report and other documentation
Correct Answer: B
Rationale: Immobilizing the leg prevents further injury in a suspected fracture, the priority action before transport.
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
- A. What is your reason for wanting such a plan?
- B. Have you talked with your provider about this?
- C. Let us discuss your rights as a couple
- D. Write your ideal plan for the next class
Correct Answer: C
Rationale: Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.
The nurse knows that
- A. these Test s are valuable screening Test s for prostatic cancer.
- B. the level of PSA is decreased in clients with renal stones.
- C. the level reflects the level of renal involvement in acid-base problems.
- D. the level of PSA is elevated in clients in early stage renal failure.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glimepiride (Amaryl). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication before breakfast.
- B. I should report sweating to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glimepiride when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, sweating indicates hypoglycemia, and alcohol increases hypoglycemia risk.
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