Nokea
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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A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
- A. 13 ml/hour.
- B. 63 ml/hour.
- C. 80 ml/hour.
- D. 125 ml/hour.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.
What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain in a lateral position using protective wrist and vest restraints.
- B. Position prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer to a wheelchair close to the nursing station for observation.
Correct Answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.
What is the main purpose of the working phase of the nurse-patient relationship?
- A. Establish a formal or informal contract that addresses the patient's problems.
- B. Implement nursing interventions that are designed to achieve expected patient outcomes.
- C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
- D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.
Correct Answer: B
Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship.
The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Therefore, documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care.