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1. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?
- A. Administer glucagon IM
- B. Give the client 4 oz of fruit juice
- C. Provide the client with peanut butter
- D. Give the client 1 L of water
Correct answer: B
Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.
2. How should a healthcare professional assess a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg pain, swelling, and redness
- B. Check for calf tenderness and administer anticoagulants
- C. Check for discoloration and monitor oxygen saturation
- D. Check for numbness and provide thrombolytic therapy
Correct answer: A
Rationale: Correct Answer: The correct way to assess a patient with suspected deep vein thrombosis (DVT) is to monitor for leg pain, swelling, and redness. These are common clinical manifestations of DVT. Choice B is incorrect because administering anticoagulants should be based on a confirmed diagnosis, not just suspicion. Choice C is incorrect because discoloration and oxygen saturation are not primary indicators of DVT. Choice D is incorrect because numbness is not a typical symptom of DVT, and thrombolytic therapy is not the first-line treatment for suspected DVT.
3. What should be included in dietary teaching for a client with chronic kidney disease?
- A. Increase potassium-rich foods in the diet
- B. Limit potassium and phosphorus intake
- C. Increase intake of protein-rich foods
- D. Increase fluid intake to prevent dehydration
Correct answer: B
Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.
4. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?
- A. Perform Kegel exercises daily
- B. Perform light exercise for 3 hours each day
- C. Avoid bathing for 3 days
- D. Avoid sitting in a chair for more than 2 hours
Correct answer: A
Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.
5. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will avoid feeding my baby for 12 hours
- B. I will apply diaper cream during each diaper change
- C. I will give my baby water between feedings
- D. I will apply warm compresses for my baby's comfort
Correct answer: B
Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.
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