Nokea
Which statement indicates understanding of a low-fiber diet?
- A. I can cut up carrots and celery sticks for my lunch.
- B. I will eat a bran muffin for my mid-morning snack.
- C. I will have oatmeal with skim milk for my breakfast.
- D. I should choose canned peaches for my fruit serving.
Correct Answer: D
Rationale: The correct answer is D because canned peaches are low in fiber compared to the other options provided. Option A contains high-fiber vegetables (carrots and celery), option B includes a bran muffin which is fiber-rich, and option C involves oatmeal which is also a good source of fiber. Therefore, choosing canned peaches aligns with a low-fiber diet.
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What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- A. Sensation of taste
- B. Sensation of pressure
- C. Sensation of smell
- D. Urge to defecate
Correct Answer: B
Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.
The nurse knows that after receiving the blood from the blood bank, it should be administered within:
- A. 1 hour
- B. 2 hours
- C. 4 hours
- D. 6 hours
Correct Answer: D
Rationale: Blood transfusions need to be administered promptly after receiving the blood from the blood bank to ensure patient safety and effectiveness. Waiting too long can lead to complications such as bacterial growth in the blood product, which can be harmful when infused. Administering the blood within 6 hours is crucial to prevent such risks. Choices A, B, and C are incorrect because waiting for 1, 2, or 4 hours respectively can increase the likelihood of complications associated with delayed transfusion.
A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?
- A. Fluid volume overload
- B. Sepsis
- C. Hyperglycemia
- D. Hypoglycemia
Correct Answer: D
Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.
A patient is being discharged with a vitamin K deficiency. What food should the nurse recommend to the patient to include in their diet?
- A. Oranges
- B. Spinach
- C. Fish
- D. Nuts
Correct Answer: B
Rationale: Spinach is an excellent source of vitamin K, which plays a vital role in blood clotting and bone health. Oranges, fish, and nuts do not contain significant amounts of vitamin K, making them less suitable choices to address a vitamin K deficiency. Therefore, the correct recommendation for a patient with a vitamin K deficiency would be to include spinach in their diet to help replenish this essential vitamin.
Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?
- A. Prostaglandins released from the cut fallopian tubes can kill sperm
- B. Sperm cannot enter the uterus because the cervical entrance is blocked
- C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
- D. The ovary no longer releases ova as there is nowhere for them to go
Correct Answer: C
Rationale: The correct answer is C: 'Sperm can no longer reach the ova because the fallopian tubes are blocked.' Tubal ligation works by blocking the fallopian tubes, preventing sperm from reaching the egg for fertilization. Choice A is incorrect because prostaglandins are not released from the cut fallopian tubes to kill sperm. Choice B is incorrect as the cervical entrance being blocked does not relate to tubal ligation. Choice D is incorrect because tubal ligation does not affect the release of ova from the ovary.