Nokea
A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?
- A. Administer pain medication as prescribed
- B. Assess the pain's nature and intensity
- C. Encourage the client to rest and apply a hot pack
- D. Notify the physician immediately
Correct Answer: B
Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.
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The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?
- A. Increase sodium intake.
- B. Engage in regular physical activity.
- C. Avoid foods high in fat.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: B
Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.
A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?
- A. Administration of IV diuretics
- B. Oxygen therapy
- C. Bed rest
- D. Dietary consultation
Correct Answer: B
Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.
During the assessment of a client who has suffered a stroke, what finding would indicate a complication?
- A. Difficulty swallowing
- B. A slight headache
- C. High blood pressure
- D. Muscle weakness on one side
Correct Answer: A
Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.
What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?
- A. Check tube placement before each feeding
- B. Flush the tube with water before and after each feeding
- C. Elevate the head of the bed to 30 degrees
- D. Administer the feeding at room temperature
Correct Answer: A
Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.
The client is being taught about a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Canned vegetables
- C. Fresh chicken
- D. Unsalted nuts
Correct Answer: B
Rationale: The correct answer is B: Canned vegetables. Canned vegetables are often high in sodium due to the preservation process, so they should be avoided on a low-sodium diet. Fresh fruits (choice A), fresh chicken (choice C), and unsalted nuts (choice D) are all low-sodium options and can be included in a low-sodium diet. It is important to choose fresh or frozen vegetables over canned ones to reduce sodium intake. Fresh chicken and unsalted nuts are also good protein sources that are naturally low in sodium, making them suitable for a low-sodium diet. Therefore, clients following a low-sodium diet should prioritize fresh, whole foods over processed or canned options.