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A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
- A. Increase fluid intake to 3 liters per day.
- B. Limit sodium intake to 2 grams per day.
- C. Avoid foods high in potassium.
- D. Increase protein intake to promote healing.
Correct Answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (A), avoiding potassium (C), and increasing protein intake (D) are not appropriate dietary instructions for heart failure management.
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During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
- A. Place a sterile drape under the client's buttocks.
- B. Instruct the client to inhale and then exhale slowly.
- C. Discard the gloves and apply new sterile gloves.
- D. Apply a sterile lubricant to the end of the catheter.
Correct Answer: D
Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretative Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric-mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care.
During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement in the client's spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client's choice
Correct Answer: B
Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.
The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?
- A. Monitor daily weights
- B. Assess skin turgor
- C. Evaluate blood pressure trends
- D. Check urine specific gravity
Correct Answer: A
Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.