Nokea
A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?
- A. Drink 1 liter of water per day.
- B. Take a laxative every morning.
- C. Increase your intake of refined grains.
- D. Walk for at least 30 minutes every day.
Correct Answer: D
Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.
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A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?
- A. Increase your intake of red meat
- B. Increase physical activity to 150 minutes per week
- C. Avoid foods high in fiber
- D. Increase sodium intake to 2,300 mg per day
Correct Answer: B
Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
- A. Increase in frequency of swallowing.
- B. Moderate sanguineous drainage on the drip pad.
- C. Bruising to the face.
- D. Absent gag reflex.
Correct Answer: A
Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.
A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct Answer: B
Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.
Which lifestyle modification should be emphasized for a client with hypertension?
- A. Increase sodium intake
- B. Reduce caffeine and alcohol intake
- C. Eat carbohydrate-rich meals
- D. Increase protein intake
Correct Answer: B
Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.
What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?
- A. Administer insulin and fluids
- B. Administer oral hypoglycemics
- C. Administer glucagon
- D. Administer insulin and monitor blood glucose
Correct Answer: A
Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.