Nutrition
a nurse is reviewing a client's medical record and notes that their BMI is 25.5. how should the nurse interpret this finding?
A) the client is overweight
B) the client is underweight
C) the client's BMI is within the normal range
D) the client is obese
A) the client is overweight
A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?
A) "Your visitors should wear a protective gown."
B) "You should receive a pneumonia vaccine every year."
C) "You should stand 1 foot away from others when coughing."
D) "You should cover your mouth with a tissue when you cough."
D) "You should cover your mouth with a tissue when you cough."
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
A) clean the perineal area at least once a day
B) empty the drainage bag when it is three-fourths full
C) flush the catheter with sterile water daily
D) disconnect the drainage bag when emptying and measuring urine
A) Clean the perineal area at least once a day
A nurse is working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take?
A) inform the nurses that the neighbor's dog did not cause the wound
B) tell the nurses that this conversation is not appropriate
C) complete an incident report upon returning to the unit
D) report the nurses' conversation to the client's provider
B) Tell the nurses that this conversation is not appropriate
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
A) eggs
B) latex
C) seafood
D) bee stings
B) latex
A nurse assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?
A) Heart rate 89/min.
B) Pink mucous membranes.
C) Pallor with scaly skin.
D) Body mass index 23
C) Pallor with scaly skin.
A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?
A) Use pictures of different food groups to help the client plan a daily menu.
B) Ask the client what they already know about meal planning.
C) Give the client a brochure with sample menus for all meals.
D) Involve the family in the discussion of the client's meal plan.
B) Ask the client what they already know about meal planning.
A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority?
A) client reports voiding three times during the night
B) client reports burning and discomforting with urination
C) the client's WBC count is 11,000/mm^3
D) the client's output was 60 mL for the past 3 hr
D) the client's output was 60 mL for the past 3 hrs
A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?
A) Administration of an enema.
B) Performance of a paracentesis.
C) Insertion of an indwelling urinary catheter.
D) Placement of an NG tube.
B) Performance of a paracentesis.
A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?
A) count the client's radial and apical pulses simultaneously with another nurse.
B)calculate the client's pulse for 30 seconds and multiply by 2
C) assist the client to a side-lying position
D) auscultate the area of the client's chest over the Erb's point
A) count the client's radial and apical pulses simultaneously with another nurse.
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
A) "Do you receive Holy Communion?"
B) "Do you follow a kosher diet?"
C) "Do you consume pork products?"
D) "Do you oppose receiving a blood transfusion if it is needed?"
C) "Do you consume pork products?"
A nurse is reinforcing teaching with a client who has hypertension and a
prescription to measure her blood pressure daily. Which of the following client
statements indicates an understanding of the teaching?
a. "I will wait 15 minutes after drinking coffee to measure my blood pressure."
b. "I will measure my blood pressure while my arm is elevated above my heart."
c. "I should remove constrictive clothing prior to measuring my blood pressure."
d. I should measure my blood pressure immediately after eating breakfast."
C. "I should remove constrictive clothing prior to measuring my blood pressure."
A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask?
A) "What types of foods have you been eating?"
B) "Are you using stool softeners or laxatives?"
C) "Have you been passing gas?"
D) "Have you had small liquid stools?"
D) "Have you had any small liquid stools?"
A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?
A) "I might file a lawsuit because of how my surgery went."
B) "Please don't tell my doctor, but I am taking my partner's oxycodone."
C) "Please don't get me out of bed this morning. It hurts too much."
D) "I don't want to take my medicine. It makes me sick to my stomach."
B) "Please don't tell my doctor, but I am taking my partner's oxycodone."
A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?
A) Fluid Overload
B) Diarrhea
C) Headache
D) Difficulty voiding
C) Headache
A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?
A) Measure the client's gastric residual before each feeding.
B) Change the bag and tubing every 24 hours.
C) Document intake and output.
D) Flush the tubing with 30 mL of water after each feeding.
A) Measure the client's gastric residual before each feeding.
A nurse is caring for a client who has a prescription for a high-protein diet to
promote wound healing following surgery. The client's religion prohibits eating
meat on particular days. Which of the following actions should the nurse take?
a. encourage the client to eat meat during this time to promote healing
b. advise the client to eat everything on the tray except the meat
c. suggest the client receive high-protein enteral feedings
d. ask the dietitian to recommend alternative food choices for the client
d. ask the dietitian to recommend alternative food choices for the client
A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider?
A) A purple-colored stoma.
B) Protrusion of the stoma.
C) A small amount of bleeding from the stoma.
D) Intestinal gas in the pouch.
A) A purple-colored stoma.
A nurse is caring for a client who has prescription for a high-protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take?
A) Encourage the client to eat meat during this time to promote healing
B) Advise the client to eat everything on the tray except the meat
C) Suggest the client receive high-protein enteral feedings
D) Ask the dietitian to recommend alternative food choices for the client
D) Ask the dietitian to recommend alternative food choices for the client
A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?
A) "Stand with your feet together and your arms at your sides."
B) "After I place the tuning fork, tell me when you no longer hear the sound"
C) "I'm going to stroke the lateral side of the bottom of your foot."
D) "Touch each fingertip as quickly as possible with your thumb."
A) "Stand with your feet together and your arms at your sides."
a nurse is discussing macronutrients with a client. Which of the following statements should the nurse make?
A) macronutrients include vitamins and minerals, which your body needs in a large amount
B) macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet
C) macronutrients include carbohydrates and fats, which your body needs very little of
D) while essential, macronutrients should be limited to weekly consumption
B) macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
A) "I know that I can change my advance directives if I need to in the future."
B) "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney."
C) "My family can overrule the decisions made by my health care surrogate."
D) "Advance directive from one state are valid in any other state."
A) "I know that I can change my advance directives if I need to in the future."
A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?
A) The client reports incisional pain as 7 on a scale of 0-10.
B) The client reports increased nausea and chills.
C) The client has an oral temperature of 38.5° (101.3° F).
D)The client has tenderness and warmth in their calf.
D)The client has tenderness and warmth in their calf.
A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following
entities?
A) an insurance agency offering a life insurance policy
B) a family member who requests the client's diagnosis
C) a physical therapist who is involved in the client's care
D) an employer completing a pre-employment screening
C) a physical therapist who is involved in the client's care
A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
A) BUN 18 mg/dL
B) a bounding pulse
C) urine specific gravity 1.045
D) prominent neck veins
C) urine specific gravity 1.045