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A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge teaching plan for the client and identifies which intervention as a priority?
- A. Exercise routines
- B. Controlling dietary intake
- C. Keeping follow-up appointments
- D. Monitoring for signs/symptoms of dehydration
Correct Answer: D
Rationale: Monitoring for dehydration is the priority for HHS, as it can progress rapidly and is life-threatening. Exercise, diet, and follow-up are important but secondary to preventing dehydration-related complications.
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The home care nurse has given instructions to a client who was recently discharged from the hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is a need for further teaching if the client makes which statement?
- A. I should inspect my feet daily.
- B. I should wear shoes and socks.
- C. I should cut my toenails straight across.
- D. I should raise my legs above the level of my heart periodically.
Correct Answer: D
Rationale: Raising legs above heart level is inappropriate for arterial ischemic ulcers, as it reduces blood flow to the extremities, worsening ischemia. Daily foot inspection, wearing shoes and socks, and cutting toenails straight across are correct care measures.
After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?
- A. Tap water
- B. Sterile water
- C. Full-strength hydrogen peroxide
- D. Half-strength hydrogen peroxide
Correct Answer: B
Rationale: After cleft lip repair, the site is cleansed with sterile water using a cotton swab after feeding and as prescribed. Agency procedure should also be followed. The parents should be instructed to use a rolling motion starting at the suture line and rolling out. Tap water is not a sterile solution. Hydrogen peroxide may disrupt the integrity of the site.
A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client?
- A. I need to eat a balanced diet.
- B. A heating pad on my leg will help soothe the leg pain.
- C. I need to take special care of my feet to prevent injury.
- D. I should walk daily to increase the circulation to my legs.
Correct Answer: B
Rationale: The application of heat directly to the extremity is contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, the direct application of heat raises the oxygen and nutritional requirements of the tissue even further. The long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition).
A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products?
- A. Milk
- B. Yogurt
- C. Spinach, chocolate, and tea
- D. Sardines, herring, and organ meats
Correct Answer: D
Rationale: The client diagnosed with a uric acid stone should limit the intake of foods that are high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. Foods with moderate levels of purines, such as red and white meats and some seafood, are also limited. Milk, yogurt, spinach, chocolate, and tea are recommended dietary changes to prevent calculi that are composed of calcium phosphate or calcium oxalate.
A clinic nurse providing home care instructions to an adolescent diagnosed with iron deficiency anemia concentrates on the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which liquid?
- A. Cola
- B. Soda
- C. Water
- D. Tomato juice
Correct Answer: D
Rationale: Iron should be administered with vitamin C-rich fluids because vitamin \mathrm{C enhances the absorption of the iron preparation. Tomato juice has a high ascorbic acid (vitamin C) content, whereas cola, soda, and water do not contain vitamin C.