Nokea
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
- A. Decrease intake of fluids after the evening meal.
- B. Drink a glass of cranberry juice every day.
- C. Drink a glass of warm decaffeinated beverage at bedtime.
- D. Consult the healthcare provider about a sleeping pill.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.
You may also like to solve these questions
Which action should the nurse implement when using the confrontation technique during a vision exam?
- A. Use an ophthalmoscope to observe the client's pupil constriction when a strong light is shone on it.
- B. Stand behind the client and direct the client to report when an object enters the peripheral field of vision.
- C. Display a series of four cards with printing of varying sizes to the client and ask which card the client sees most clearly.
- D. Sit facing the client, look directly at the client's face, and move an object inward from the periphery.
Correct Answer: D
Rationale: During a vision exam, the confrontation technique is used to assess peripheral vision. By sitting facing the client and moving an object inward from the periphery while looking directly at the client's face, the nurse allows the client to indicate when the object enters the visual field. This method helps in determining the extent of the client's peripheral vision accurately. Choices A, B, and C are incorrect as they do not describe the appropriate method for using the confrontation technique during a vision exam. Choice A involves using an ophthalmoscope to observe pupil constriction, choice B involves testing the peripheral field of vision without the confrontation technique, and choice C describes the Snellen eye chart test for visual acuity, which is not related to the confrontation technique.
A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client's daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?
- A. Refer to the risk manager
- B. Notify the healthcare provider
- C. Discontinue the ventilator
- D. Review the medical record
Correct Answer: B
Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.
Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?
- A. Superficial veins are more easily found in the feet and ankles.
- B. A decreased flow rate could lead to thrombosis formation.
- C. It is more challenging to move a cannulated extremity when using the leg or foot.
- D. Veins in the feet and ankles are located deep, making the procedure more painful.
Correct Answer: B
Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.
After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?
- A. Is voiding normally.
- B. Has urinary retention.
- C. Has developed renal failure.
- D. Needs an indwelling catheter.
Correct Answer: B
Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.
The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?
- A. Limit sodium intake to 2,300 mg per day
- B. Engage in moderate exercise for 30 minutes daily
- C. Consume a diet high in saturated fats
- D. Avoid alcohol consumption completely
Correct Answer: B
Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.