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1. A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?
- A. A client with a weight of 128 lb and height of 70 inches
- B. A client with a weight of 150 lb and height of 68 inches
- C. A client with a weight of 200 lb and height of 72 inches
- D. A client with a weight of 133 lb and height of 60 inches
Correct answer: A
Rationale: To determine a healthy BMI, we need to calculate it using the formula: BMI = weight (lbs) / height^2 (inches) x 703. For choice A, BMI = 128 / (70 x 70) x 703 = 18.38, which falls within the healthy BMI range of 18.5-24.9. Therefore, choice A is correct. Choices B, C, and D have BMIs of 22.8, 27.1, and 26.1, respectively, which are outside the healthy range. Thus, choices B, C, and D are incorrect.
2. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:
- A. Set and turn on the alarm of the oximeter
- B. Do nothing since there is no identified problem
- C. Cover the fingertip sensor with a towel or bedsheet
- D. Change the location of the sensor every four hours
Correct answer: B
Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.
3. The GAUGE size in ET tubes determines:
- A. The external circumference of the tube
- B. The internal diameter of the tube
- C. The length of the tube
- D. The tube’s volumetric capacity
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. In obtaining a urine specimen for culture and sensitivity on a catheterized patient, the nurse is correct if:
- A. Clamp the catheter for 30 minutes, Alcoholize the tube above the clamp site, Obtain a sterile syringe and draw the
- B. Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self sealing port
- C. Disconnect the drainage bag, obtain a sterile syringe and draw the specimen from the drainage bag
- D. Disconnect the tube, obtain a sterile syringe and draw the specimen from the tube
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
5. Which vitamin's recommended dietary allowance (RDA) is significantly increased during pregnancy?
- A. Folate
- B. Thiamine (B1)
- C. Riboflavin (B2)
- D. Niacin (B3)
Correct answer: A
Rationale: The correct answer is A: Folate. During pregnancy, the recommended dietary allowance (RDA) for folate is significantly increased to support fetal development and prevent neural tube defects and other congenital anomalies. Folate plays a crucial role in DNA synthesis and cell growth, making it essential for the rapidly dividing cells of the developing fetus. Thiamine (B1), Riboflavin (B2), and Niacin (B3) are important vitamins, but their RDAs do not undergo as significant an increase during pregnancy as folate's RDA does.
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