The correct answers are #2 and #3
Option #1 is not correct because it is not a protein rich food or “high” in protein.
Option #4 is not correct because although the flour if “fortified” it is not protein rich and do not provide enough protein.
Option #5 is not correct because she cannot tolerate milk products and yogurt is milk based.
Options #2 and #3 are correct because they are not milk based and are non-meat but protein rich vegetable products.
Tip: Read the question carefully. The situation is about a woman who is pregnant and needs to find alternate foods to meet her protein needs. She does not eat meat and so needs protein rich foods. She cannot tolerate milk products. Take away the milk products and any other foods that are not “rich in protein”
The correct answer is #1
Remember that fetal status is the most important assessment to do in this situation. It takes very little time to do this assessment and while doing it, other data is obtained; uterine irritability and fetal oxygen needs. In situations where birth may be imminent, remember that fetal status is the priority, followed by Labor status (option #2), then maternal status (option #3) and finally documentation – which is important, but would follow all the other steps.
Tip: Remember the nursing process begins with assessment; this means 1, 2, or 3 must be a priority. With labor – which could very likely be imminent in a situation like this – the nurse assesses in the order of priority: fetus " labor status " mother
Select all that apply and place them in order of priority.
The correct answers are #3, #2, #4 and #5 – in this order
The rationale for eliminating option #1 is that you need to change any client’s position at least every 2 hours to prevent skin breakdown. The first priority, option #3, for a client who has undergone orthopedic surgery is to check for circulation, sensation and movement (CSM checks) as the goal is to assess for and prevent neurovascular injury. The second priority is response option #2 is to maintain body alignment using pillows and other padded (bolsters) devices. Remember a SPICA cast covers the hips and at least one entire leg or both. There is a section cut out so the client can void or defecate (look this up on the internet!). It becomes vitally important to make sure alignment is achieved for comfort and reduction of potential injury. The third priority is option#4; giving a child any small toy or candy would be an “invitation” for injury! Children, even 6-year olds, love to stick things into casts and such that would inevitably cause a risk for infection through injury. The fourth priority, option #5, is extending an invitation for visits from classmates and friends. Of course you would need to follow the guidelines in terms of visitation from the agency, but this is important for the child’s well-being. Some of you may not have chosen this option because you are thinking of the agency policy – but that is not part of this situation.
The correct answer is option #3.
Knowledge and application of knowledge about the condition (i.e., prevalent theory about dynamics of codependency and knowledge of the most effective strategies for interpersonal interventions) is needed to distance oneself, in order to avoid the common pitfall of becoming emotionally engulfed. Options #1 and #4 are incorrect: Personal history (#1) and feelings (#4) interfere with needed objectivity in the emotionally charged area of personal experience with alcohol dependency. Option #2 is incorrect because lack of personal experience is not the issue. The RN needs to assess application of knowledge, and skill in use of therapeutic interventions.
Tip: Here again is the word, ASSESS and in terms of delegation; the RN must know the clients and their needs and assess the care providers in terms of knowledge, scope, skill level and experience when delegating.
The correct answers are options #1, # 2 and # 5.
Options #1 and #2 are Parkinsonian symptoms that are also found with EPS. Option #5 is a manifestation found with dystonia, also a symptom of EPS. Option #3 is incorrect because it is an autonomic symptom that is not related the EPS. Option #4 is incorrect because a thought process disorder and not found with EPS, in fact the antipsychotic is administered to help with those symptoms.
Tip: Remember EPS affect the voluntary muscle movements and skeletal muscles. Isolate those options that are not related to movement or muscles and what is remaining are the symptoms of EPS.
The correct answers are options #1, #2, #3, and #6.
These are all foods high in potassium. Digitalis toxicity is likely developed when the potassium is low. In addition, clients taking digoxin usually are using a diuretic, which depletes the serum potassium store. Foods high in potassium include: the whole grains, citrus fruits, apricots, bananas and potatoes. The other foods are not sources of potassium.
Tip: Remember, know food sources for important electrolytes, vitamins, minerals etc. that help or hinder a physical condition. Potassium is a very important electrolyte and knowing the common food sources is equally important.
The correct answer is option #2.
For severe/acute pain bone pain an opiate is the most effective and the IV route would deliver the medication more quickly. It is very unlikely that tolerance and dependence would develop during short term use. Acetaminophen is given for mild to moderate pain (option #1). Meperidine (option #3) is shorter acting than morphine sulfate and forms a toxic metabolite that stimulates the central nervous system. Meperidine is not the drug of choice for the management of acute or chronic pain – it is rarely prescribed due to the side effects. Gabapentin is classified as an anti-convulsant and is used for chronic nerve pain, not for severe/acute bone pain.
Tip: Know that NCLEX will only give you the generic name for medications. Review the common medications for a variety of disorders. Acute/severe pain is best treated using an intravenous (IV) medication that is an opiate derivative.
The correct answer is option #4.
This type of tube has inflatable balloons that are positioned in the esophagus and stomach; the tube may become dislodged and obstruct the airway. If airway obstruction is observed, the tube should not be cut; instead, the balloons should be deflated and the tube, or tubes, removed. An acute illness will increase gastric acidity, but routine testing (option #1) is not done in a client with this tube. The client should receive an acid reducing agent to prevent hyper acidity. The tube is used to stop esophageal bleeding, so a hematest (option #2) result would be positive; this finding does not indicate a problem with the tube. The tube is inserted via the nose, so communication (option #3) would not be impaired.
Tip: If you know nothing about a Sengstaken-Blakemore tube remember a first priority action in dealing with any “tube in the esophagus” would be to ensure the airway remains patent, as complications arise with potential dislodgement. Defer to nursing priority actions that maintain patient safety and in this case preserve the patient’s airway.