Nokea
The nurse returns to the nurse's station after making client rounds and finds four phone messages.
Which of the following messages should the nurse return FIRST?
- A. A client with hepatitis A who states, 'My arms and legs are itching.'
- B. A client with a cast on the right leg who states, 'I have a funny feeling in my right leg.'
- C. A client with osteomyelitis of the spine who states, 'I am so nauseous that I can't eat.'
- D. A client with arthritis who states, 'I am having trouble sleeping at night.'
Correct Answer: B
Rationale: Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct-may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority
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The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
An adult male is admitted with urolithiasis. The nurse expects which orders for this client? Select all that apply.
- A. Push fluids
- B. Strain all urine
- C. Medicate for pain PRN
- D. Clean catch daily
- E. Daily catheterizations
- F. Clear liquid diet
Correct Answer: A,B,C
Rationale: Pushing fluids promotes stone passage, straining urine captures stones for analysis, and pain medication addresses colic in urolithiasis. Clean catch, catheterization, or clear liquids are not standard.
A 52-year-old woman has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-in incision.
Which of the following behaviors, if performed by the student nurse, would require an intervention by the nurse?
- A. The old dressing is saturated with sterile saline before it is removed.
- B. Dry dressings are placed over the saline-saturated gauze in the incision.
- C. Wound debris and necrotic tissue are removed with the old dressing.
- D. The gauze is saturated with sterile saline before it is packed into the incision.
Correct Answer: A
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) correct-should be removed dry so wound debris and necrotic tissue are removed with old dressing (2) done to protect clothing and bedding (3) purpose of wet-to-dry dressing (4) appropriate procedure