A nurse is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a
BMI of
... [Show More] an overweight client? A. 18.5
B. 24.9
C. 25
D. 32
1. A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?
A. 2
B. 5
C. 7
D. 9
A. 2
2. A nurse is caring for a client with a closed head injury. When pressure is applied to client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is the client's Glascow Coma Score?
A. 4
B. 7
C. 9
D. 10
B. 7 (comatose)
Rationale:
Eye Opening (ranges from 4-
1) 4 = spontaneous 3 = to voice
2 = to pain 1 =
none
Verbal (ranges from 5- 1) 5 = oriented
4 = confused
3 = inappropriate words 2
= incomprehensible sounds 1= none Motor (raged from 6- 1) 6 = obeys command
5 = localizes pain 4 =
withdraws
3 = flexion (decorticate posturing) 2
= extension (decerebrate posturing) 1 = none
3. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
A. A client who is able to bear full weight on both lower extremities.
B. A client who has bilateral leg braces due to paralysis of the lower extremities.
C. A client who has a right femur fracture with no weight bearing on the affected leg.
D. A client who has bilateral knee-replacements with partial weight bearing on both legs.
leg.
Rationale: A three-point gait requires the client to bear all of his weight on one foot. With a three-point gait, the client bears weight on both crutches and then on
the uninvolved leg, repeating the sequence. The affected leg does not touch the
ground.
4. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis if hypertension. Which of the following statements by the client indicates a need for further teaching?
A. "I will limit my intake of red meat to twice weekly."
B. "I can have dairy in moderate portions daily."
C. "I can have fish two times a week."
D. "I can drink wine in moderation."
A. "I will limit my intake of red meat to twice weekly."
Rationale: Following the Mediterranean diet, red meat should be limited to two times monthly. The client should have dairy in moderate portions daily to weekly.
The intake of fish and seafood is at least two times per week. Drinking wine is
acceptable in moderation.
5. A nurse is providing dietary education to a client with cholecystitis who has been prescribed a low-fat diet. Which of the following meal selections by the
client indicates understanding of education?
A. Roast beef with gravy, mashed potatoes, ice cream
B. Macaroni and cheese, salad, pudding
C. Creamed chicken on a roll with peas
D. Roast turkey, rice pilaf, green beans
6. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvis organ prolapse. What exercise will the client need to perform? A. Kegel exercises
B. Isometric exercises
C. Circumduction exercises
D. Uterine extension exercises
A. Kegel exercises Rationale: Kegel exercises strengthen the pelvic floor muscles, which results in reduction or prevention of pelvic prolapse and stress urinary incontinence. The other mentioned exercises have no direct effect on prevention or reduction of a cystocele. [Show Less]