A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

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Question 1 of 5

A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

Correct Answer: B

Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.

Question 2 of 5

After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

Correct Answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.

Question 3 of 5

A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?

Correct Answer: B

Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.

Question 4 of 5

A nurse is reinforcing teaching with the mother of a 9-month-old infant regarding appropriate dietary choices. Which of the following observations by the nurse indicates a need for further teaching?

Correct Answer: C

Rationale: The correct answer is C. Infants should not consume more than 24 ounces of milk a day as it can lead to iron deficiency anemia and other issues. Choices A and B demonstrate appropriate dietary choices for a 9-month-old, as they involve providing the infant with family foods and appropriate finger foods. Choice D is also appropriate as it shows the infant is transitioning to drinking from a cup.

Question 5 of 5

A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

Correct Answer: D

Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.

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