Nokea
A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase
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The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
A nursing assistant states that her five-year-old child has developed chickenpox.
It would be MOST important for the nurse to ask which of the following questions?
- A. Have your other children had chickenpox?'
- B. Does your child have a temperature?'
- C. Have you had the chickenpox?'
- D. Do you have someone to watch your child?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings would be of GREATest concern to the nurse?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium of 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium of 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose level of 180 mg/dL.
- B. Temperature of 100.4°F (38°C).
- C. Weight gain of 1 kg in 24 hours.
- D. Potassium level of 3.8 mEq/L.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests infection, a serious complication in TPN due to catheter-related bloodstream infections. Options A, C, and D are less urgent: hyperglycemia is common and manageable, rapid weight gain may indicate fluid overload, and potassium 3.8 mEq/L is normal.