Nokea
A client is provided instructions for a low-sodium diet. Which statement by the client indicates an understanding of the diet?
- A. I'll miss eating tomatoes.
- B. I'll enjoy eating take-out more frequently.
- C. I'll avoid potato chips and cheese.
- D. I'll miss eating celery.
Correct Answer: C
Rationale: Potato chips and cheese are high-sodium foods, and avoiding them shows understanding of a low-sodium diet. Tomatoes and celery are low-sodium, and take-out is often high-sodium.
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Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?
- A. Place the bed in Trendelenburg position and call the physician
- B. Take the client's vital signs and administer Benadryl 50 mg PO
- C. Place the bed in high Fowler's position and call the physician
- D. Start an Aminophylline drip and call the physician
Correct Answer: C
Rationale: Symptoms suggest an allergic reaction, possibly anaphylaxis from shrimp. Placing the client in high Fowler's position facilitates breathing, and calling the physician ensures rapid intervention.
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: essential if client is to perform ADLs
According to Erikson's stages of physical development, school-age children 5 - 12 years old typically face which psychological crisis?
- A. ego integrity versus despair
- B. industry versus inferiority
- C. trust versus mistrust
- D. ego identity versus role confusion
Correct Answer: B
Rationale: School-age children (5-12) face industry vs. inferiority, focusing on developing competence and self-esteem through tasks and skills.
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.