a 35 year old latin american client wishes to lose weight to reduce her chances of developing heart disease and diabetes the client states i do not kn

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

A. Provide her with copies of the approved dietary guidelines from the American Diabetic Association and the American Heart Association.
B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
C. Provide a high-protein diet plan for the client.
D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

2. The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?

A. Use the defrost setting on microwave ovens to warm bottles.
B. When refrigerating formula, discard partially used bottles after 24 hours.
C. When using formula concentrate, mix one part concentrate and two parts water.
D. If a portion of one bottle is left for the next feeding, discard it.

Correct answer: B

Rationale: The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is crucial to be cautious when heating bottles in a microwave to prevent milk from becoming superheated. The defrost setting is recommended, and the formula's temperature should always be checked before feeding the baby. Choice B, which advises to discard partially used bottles of refrigerated formula after 24 hours, is also correct. This is important to prevent the introduction of pathogens by the baby into the formula. Choice C, recommending mixing one part formula concentrate with two parts water, is essential for ensuring the correct dilution. Choice D, suggesting to discard any remaining portion of a bottle for the next feeding, is incorrect. It is not necessary to discard the remaining portion if it has been refrigerated promptly and used within a safe time frame. Adding fresh formula to a partially used bottle is not recommended, as it can lead to the growth of pathogens that may be transferred to the new formula.

3. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?

A. emotional support to help the family cope with feelings of guilt about the infant's condition
B. administration of MICRhoGam to the woman within 72 hours of delivery
C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
D. lab analysis of maternal Direct Coombs' test

Correct answer: A

Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.

4. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?

A. "I will need to avoid eating excessive leafy greens."?
B. "It's best to take this medication with food."?
C. "I can't wait to get back to my nightly glass of wine."?
D. "I should try to take this medication at the same time every day."?

Correct answer: C

Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.

5. How should a nurse listen to the breath sounds of a client?

A. Ask the client to lie prone.
B. Ask the client to breathe in and out through the nose.
C. Hold the bell of the stethoscope lightly against the chest.
D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.