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1. A client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Assign an assistive personnel to feed the client.
- B. Explain to the client that their tray is here and guide their hands to it.
- C. Describe to the client the location of the food on the tray.
- D. Ask the client if they would prefer a liquid diet.
Correct answer: C
Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.
2. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
- A. Limit suppliers to a few so that quality is maintained
- B. Implement a regular inventory of supplies and equipment
- C. Adherence to manufacturer’s recommendation
- D. Implement a regular maintenance and testing of alarm systems
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
3. What is a likely effect on a patient whose lab results reveal hypoalbuminemia?
- A. Infection
- B. Rickets
- C. Hypertension
- D. Edema
Correct answer: D
Rationale: Hypoalbuminemia, which refers to low albumin levels in the blood, is often associated with edema. Albumin helps maintain oncotic pressure, which keeps fluid within blood vessels. When albumin levels are low, this pressure decreases, leading to fluid leakage from the blood vessels into the surrounding tissues, resulting in edema. The other choices are less likely effects of hypoalbuminemia. Hypoalbuminemia doesn't directly cause infections (Choice A), rickets (Choice B) caused by vitamin D deficiency, or hypertension (Choice C) associated with factors like high sodium intake, obesity, and genetic predisposition.
4. A healthcare professional is preparing a list of resources in a community where nutritional status is significantly influenced by economics. What should the professional recommend?
- A. Public service announcement on healthy eating
- B. Educational programs on food safety
- C. The MyPyramid food guidance system
- D. The Supplemental Nutrition Assistance Program (SNAP)
Correct answer: D
Rationale: The correct answer is D, the Supplemental Nutrition Assistance Program (SNAP). SNAP provides financial assistance to help low-income individuals purchase food, directly addressing economic barriers to nutrition. Choices A, B, and C do not directly address the economic aspect of the community's nutritional status. A public service announcement on healthy eating may raise awareness but does not provide financial assistance. Educational programs on food safety focus on a different aspect of nutrition. The MyPyramid food guidance system is a tool for healthy eating but does not address the economic challenges faced by the community.
5. Reducing the amount of trans fat in the diet is an effective method of decreasing the risk of CHD. Which food is most likely a source of trans fat?
- A. hot dogs
- B. whole milk
- C. fatty fish
- D. potato chips
Correct answer: D
Rationale: The correct answer is D: potato chips. Potato chips, especially when fried in hydrogenated oils, are a common source of trans fats, which are linked to an increased risk of coronary heart disease (CHD). Hot dogs (choice A) can also contain trans fats if made with processed meats and added fats. Whole milk (choice B) and fatty fish (choice C) do not typically contain trans fats, making them less likely sources compared to potato chips.
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