Nokea
The nurse is caring for clients in the outpatient clinic. A young adult female is seeking help for weight loss. Her weight is 257 pounds, and she is 5'7'' tall.
Which of the following indicates the MOST appropriate diet choices for breakfast?
- A. Applesauce, cream of wheat, toast.
- B. Scrambled eggs and toast, one slice of bacon.
- C. One glass of grapefruit juice.
- D. Bagel with two ounces of cream cheese and a banana.
Correct Answer: A
Rationale: Strategy: Determine the topic of the question. (1) correct-breakfast with some substance won't leave her feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content
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The nurse is caring for a client with a history of type 2 diabetes who is receiving exenatide (Byetta) 10 mcg SC bid. Which of the following symptoms should the nurse report immediately?
- A. Mild nausea
- B. Upper abdominal pain
- C. Occasional thirst
- D. Mild fatigue
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious exenatide side effect. Options A, C, and D are less urgent: nausea is common, thirst is expected, and fatigue is nonspecific.
A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
It is MOST important for the nurse to take which of the following actions?
- A. Perform a straight catheterization.
- B. Offer the client the bedpan.
- C. Put the baby to breast.
- D. Massage the uterine fundus.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
- A. My wife complains because I snore off and on all night.'
- B. I like to nap in the afternoon.'
- C. I wake up early every morning.'
- D. My muscles seem to jerk as I fall asleep.'
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.
Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
- A. color of the medication solution.
- B. patient's pulse and temperature.
- C. time of the last analgesic dose the patient received.
- D. patency of the patient's vein.
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
- A. The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate injection sites.
- B. The second dose can be given at 1 to 2 months of age.
- C. The third dose should be given at least 16 weeks from the second dose.
- D. The last dose in the series is not to be given before age 24 weeks.
Correct Answer: C
Rationale: The third dose should be given at least 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information.