Nokea
Which of these food choices, if selected by a client with diarrhea, would indicate the need for further teaching about dietary management?
- A. orange juice
- B. tuna
- C. eggs
- D. macaroni
Correct Answer: A
Rationale: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.
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Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.
The nurse is to administer cefazolin sodium 1 g in 100 mL 0.9% NaCl over 30 minutes. At what rate in mL/hour should the nurse plan to set the infusion pump?
Correct Answer: 200
Rationale: 100 mL/ 0.5 hours = 200 mL/hour.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
- A. Breath sounds can be heard bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88 BPM
- D. Client is unable to speak
Correct Answer: C
Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.