Nokea
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
- A. Liquids as desired.
- B. Small, easily digested meals.
- C. Three regular meals per day.
- D. Nothing by mouth.
Correct Answer: B
Rationale: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.
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Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
- A. Tell the client that 'ringing' in the ears is associated with the aging process.
- B. Refer the client to have a hearing test.
- C. Schedule the client for audiometric testing.
- D. Explain to the client that the 'ringing' may be related to the aspirin.
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
- A. Increase the amount of iron in the client's diet.
- B. Apply lotion to the lower extremities.
- C. Elevate the legs.
- D. Consult the oncologist.
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
- A. Remove the dressing and leave the incision open to air.
- B. Remove the drain if wound drainage is minimal.
- C. Gently irrigate the drain to remove exudate.
- D. Clean the area around the drain moving away from the drain.
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize