Nokea
A client is receiving treatment for hypothyroidism. Which of these assessments would be most concerning to the nurse?
- A. Heart rate of 70 beats per minute
- B. Blood pressure of 110/70 mm Hg
- C. Respiratory rate of 16 breaths per minute
- D. Temperature of 98.6 degrees Fahrenheit
Correct Answer: B
Rationale: A blood pressure of 110/70 mm Hg would be most concerning to the nurse because changes in blood pressure can indicate worsening hypothyroidism, potentially leading to complications such as myxedema coma. A heart rate of 70 beats per minute, a respiratory rate of 16 breaths per minute, and a temperature of 98.6 degrees Fahrenheit are within normal ranges and not typically directly associated with hypothyroidism complications.
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The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm reset button on the ventilator
Correct Answer: B
Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.
A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?
- A. Most of my calories each day should be from fats.
- B. I should eat more calories from complex carbohydrates than anything else.
- C. Simple sugars are needed more than other calorie sources.
- D. Protein should be my main source of calories.
Correct Answer: B
Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.
A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct Answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?
- A. 1 medium apple
- B. 3 oz of lean beef
- C. 1 tbsp of cream cheese
- D. 1 cup of kale
Correct Answer: D
Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?
- A. It is a condition in which one or more tumors, called gastrinomas, form in the pancreas or in the upper part of the small intestine (duodenum).
- B. It is critical to promptly report any findings of peptic ulcers to your health care provider.
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors.
- D. The average age at diagnosis is 50 years, and peptic ulcers may occur in unusual areas of the stomach or intestine.
Correct Answer: B
Rationale: Prompt reporting of peptic ulcers is crucial in managing Zollinger-Ellison syndrome to prevent complications and guide treatment. While choices A, C, and D provide relevant information about the condition and its treatment, the most important aspect in the client's care is the prompt reporting of peptic ulcers. This is because untreated peptic ulcers in Zollinger-Ellison syndrome can lead to serious complications such as gastrointestinal bleeding or perforation. Therefore, ensuring timely communication with the healthcare provider is essential for effective management of the condition.