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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
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Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glipizide (Glucotrol). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication 30 minutes before breakfast.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should report sweating or shakiness to my doctor.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glipizide when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, alcohol increases hypoglycemia risk, and sweating/shakiness indicate hypoglycemia.
A child at summer camp comes to see the camp nurse 10 minutes after being stung by a bee. The child complains of tingling around her mouth and tightness in her chest. The nurse's first action is summon help and to:
- A. Administer $\mathrm{O}_2$ at $4 \mathrm{~L} / \mathrm{min}$ by nasal cannula.
- B. Apply a tourniquet proximal to the bee sting and give epinephrine subcutaneously.
- C. Administer $\mathrm{O}_2$ at $6 \mathrm{~L} / \mathrm{min}$ and give Benadryl (Diphenhydramine) $25 \mathrm{mg}$ PO.
- D. Reassure the child that she is only excited due to the sting.
Correct Answer: B
Rationale: Tingling and chest tightness suggest anaphylaxis; epinephrine is the first-line treatment, and a tourniquet may slow venom spread.
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: Independence. In Erikson's theory of development, toddlers struggle to assert independence, often using the word 'no' to establish autonomy.