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A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?
- A. Liver
- B. Milk
- C. Beans
- D. Eggs
Correct Answer: C
Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.
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A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place the client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.
A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.
A nurse is caring for four clients. The nurse should observe which of the following clients for a risk of vitamin B6 deficiency?
- A. A client who has cystic fibrosis
- B. A client who has chronic alcohol use disorder
- C. A client who takes phenytoin for a seizure disorder
- D. A client who is prescribed rifampin for tuberculosis
Correct Answer: B
Rationale: Chronic alcohol use disorder can lead to vitamin B6 deficiency due to impaired absorption and increased excretion of the vitamin. While clients with cystic fibrosis may be at risk for fat-soluble vitamin deficiencies, such as vitamins A, D, E, and K, they are not specifically at high risk for vitamin B6 deficiency. Clients taking phenytoin are at risk for folate deficiency, not vitamin B6. Clients prescribed rifampin for tuberculosis are at risk for vitamin D deficiency, not vitamin B6.
The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?
- A. Yellowing of the skin and eyes
- B. Presence of spider angiomas on the skin
- C. Ascites and peripheral edema
- D. Clay-colored stools and dark urine
Correct Answer: D
Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.
A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct Answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.