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Questions 164

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Question 1 of 5

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

Correct Answer: C

Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Question 2 of 5

The nurse is caring for an elderly woman who had surgery on her right foot yesterday. The woman had a broken left arm three months ago and has osteoarthritis. Which type of assistive device will probably be most appropriate for this client?

Correct Answer: C

Rationale: A walker provides maximum stability for an elderly woman with recent foot surgery, prior arm injury, and osteoarthritis, ensuring safe ambulation.

Question 3 of 5

The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?

Correct Answer: C

Rationale: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.

Question 4 of 5

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

Correct Answer: C

Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.

Question 5 of 5

The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to

Correct Answer: C

Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.

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