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A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
- A. Monitor for leg cramps.
- B. Increase sodium intake.
- C. Monitor for headache.
- D. Take the medication at bedtime.
Correct Answer: A
Rationale: Rationale: Correct answer is A. Leg cramps are a common side effect of hydrochlorothiazide due to electrolyte imbalance. Monitoring for leg cramps will help in identifying and managing this side effect promptly. Choices B and D are incorrect as hydrochlorothiazide can lead to electrolyte depletion, so increasing sodium intake is not recommended, and taking the medication at bedtime may increase nighttime urination. Choice C is incorrect as headaches are not a common side effect of hydrochlorothiazide.
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A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?
- A. Prevent the spread of infection with good household cleaning practices.
- B. Limit handwashing to once a day to avoid skin damage.
- C. Avoid sharing towels with other people in the household.
- D. Do not disinfect surfaces in the home with bleach.
Correct Answer: A
Rationale: The correct answer is A: Prevent the spread of infection with good household cleaning practices. The nurse should include this statement in the discharge instructions because individuals with AIDS have weakened immune systems, making them more susceptible to infections. Good household cleaning practices can help prevent the spread of infections to the client and others.
Incorrect choices:
B: Limit handwashing to once a day to avoid skin damage - This is incorrect as frequent handwashing is crucial to prevent the spread of infections.
C: Avoid sharing towels with other people in the household - This is incorrect as sharing towels can lead to the transmission of infections.
D: Do not disinfect surfaces in the home with bleach - This is incorrect as disinfecting surfaces with bleach is important to kill harmful pathogens.
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
- A. C-reactive protein
- B. Erythrocyte sedimentation rate (ESR)
- C. White blood cell count
- D. Hematocrit
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (RA) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C, D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.