Extract:

Question 1 of 5

The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?

Correct Answer: A

Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.

Question 2 of 5

A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?

A. Administer regular insulin intravenously. B. Administer potassium supplements. C. Restrict fluid intake. D. Administer sodium bicarbonate.

Correct Answer: A

Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.

Question 3 of 5

A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?

A. Based on urine output plus 500 mL B. 1,000 mL regardless of weight C. 20 mL/kg of body weight D. Unlimited unless edema is present

Correct Answer: A

Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.

Question 4 of 5

The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.

A. Amount of alcohol consumed daily. B. Use of antacids. C. Dietary intake of fiber. D. Use of Vitamin K supplements. E. Intake of fruit juices.

Correct Answer: A, B

Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.

Question 5 of 5

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.

A. Having suction equipment readily available B. Keeping all the lights on in the room at night C. Keeping a padded tongue blade at the bedside D. Assisting the client to ambulate in the hallway E. Monitoring the client closely while showering F. Locking the client's bed in its lowest position

Correct Answer: A,D,E,F

Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.