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Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
- A. Apples.
- B. Tomato juice.
- C. Whole wheat bread.
- D. Beef tenderloin.
Correct Answer: B
Rationale: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.
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A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
- A. Remove all tubes and I.V. lines.
- B. Cover the body with a sheet.
- C. Notify the family.
- D. Transport the body to the morgue.
- E. Notify the chaplain.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
A 27-year-old female has had elective nasal surgery for a deviated septum. Which of the following would indicate that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Nausea.
- B. Repeated swallowing.
- C. Increased respiratory rate.
- D. Increased pain.
Correct Answer: B
Rationale: Repeated swallowing may indicate blood trickling down the throat (postnasal drip), a sign of bleeding. Nausea, increased respiratory rate, and pain are less specific indicators of bleeding.
The nurse is caring for a client with cancer experiencing chronic pain and episodes of breakthrough pain. Which prescription should the nurse request from the primary healthcare provider (PHCP) to provide effective pain control?
- A. Hydromorphone via patient-controlled analgesia (PCA)
- B. Morphine intramuscular (IM) as needed (PRN) for pain
- C. Oxycodone extended-release (ER) by mouth (PO)
- D. Ketorolac via intravenous (IV) push
Correct Answer: A
Rationale: Hydromorphone via PCA allows for both continuous and patient-controlled dosing, ideal for managing chronic cancer pain with breakthrough episodes.
Which symptom suggests a complication post-renal surgery?
- A. Urine output of 25 mL/hour.
- B. Temperature of 99°F.
- C. Mild incisional pain.
- D. Clear urine.
Correct Answer: A
Rationale: Low urine output (25 mL/hour) may indicate obstruction or renal impairment.