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A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?
- A. Administer morphine sulfate.
- B. Place the client in a high Fowler's position.
- C. Initiate continuous ECG monitoring.
- D. Prepare the client for intubation.
Correct Answer: B
Rationale: The correct action for the nurse to take first is to place the client in a high Fowler's position (Choice B). This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and improving ventilation. With severe shortness of breath and pink, frothy sputum, the priority is to optimize respiratory function. Administering morphine sulfate (Choice A) may be indicated later for pain and anxiety but is not the immediate priority. Initiating continuous ECG monitoring (Choice C) is important but not as urgent as addressing the respiratory distress. Preparing the client for intubation (Choice D) should be considered if respiratory distress worsens, but initial interventions should focus on improving oxygenation through positioning.
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A client with a history of hypertension is prescribed hydrochlorothiazide. Which instruction should the nurse include in the client's teaching?
- A. Take this medication in the morning.
- B. Avoid foods high in potassium.
- C. Monitor your blood pressure regularly.
- D. Decrease your intake of high-sodium foods.
Correct Answer: C
Rationale: The correct answer is C: "Monitor your blood pressure regularly." This instruction is crucial for a client with hypertension prescribed hydrochlorothiazide because the medication helps lower blood pressure. By monitoring their blood pressure regularly, the client can track the effectiveness of the medication and ensure it is within the target range. This allows for early detection of any potential issues or the need for medication adjustments.
Option A is incorrect because while it is generally recommended to take hydrochlorothiazide in the morning, it is not the most critical instruction for this scenario. Option B is incorrect as hydrochlorothiazide can cause hypokalemia, so avoiding high potassium foods is not necessary. Option D is also important but not as crucial as monitoring blood pressure, as reducing high-sodium foods can help manage hypertension but is not specific to hydrochlorothiazide.
A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?
- A. Thiamine (Vitamin B1)
- B. Cyanocobalamin (Vitamin B12)
- C. Folic acid
- D. Vitamin D
Correct Answer: A
Rationale: The correct answer is A: Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, causing neurological symptoms like confusion and unsteady gait (Wernicke's encephalopathy). Thiamine is crucial for brain function and alcohol interferes with its absorption. Vitamin B12 (choice B) deficiency can also cause neurological symptoms but is less likely in this case. Folic acid (choice C) deficiency can lead to anemia and neural tube defects, not directly related to the symptoms described. Vitamin D (choice D) deficiency typically presents with bone pain and muscle weakness, not confusion and gait issues.
A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?
- A. Walk barefoot whenever possible to toughen your feet.
- B. Soak your feet in hot water daily to improve circulation.
- C. Trim your toenails straight across to prevent ingrown toenails.
- D. Use a heating pad to keep your feet warm.
Correct Answer: C
Rationale: Correct Answer: C - Trim your toenails straight across to prevent ingrown toenails.
Rationale:
1. Trimming toenails straight across helps prevent ingrown nails.
2. Ingrown nails can lead to infection, especially risky for diabetics due to poor wound healing.
3. Walking barefoot toughens feet, increasing risk of injury.
4. Soaking in hot water can cause burns or skin damage.
5. Using a heating pad can lead to burns or decreased sensation in feet, increasing injury risk.
Summary:
Option C is correct as it directly addresses a common issue in diabetic foot care - ingrown toenails. Options A, B, and D pose risks of injury or damage to the feet, which is detrimental for diabetic individuals.
The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Increased respiratory rate.
- B. Decreased oxygen saturation.
- C. Clear lung sounds.
- D. Elevated white blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.
A client with hypertension is receiving dietary education from a nurse. Which recommendation should the nurse include?
- A. Increase your intake of saturated fats.
- B. Limit your sodium intake to less than 2 grams per day.
- C. Avoid foods high in potassium.
- D. Consume at least three alcoholic beverages daily.
Correct Answer: B
Rationale: The correct answer is B: Limit your sodium intake to less than 2 grams per day. Sodium restriction is crucial in managing hypertension as it helps reduce blood pressure. Excessive sodium intake can lead to fluid retention and increased blood volume, worsening hypertension. This recommendation aligns with evidence-based guidelines for hypertension management.
Incorrect choices:
A: Increasing saturated fat intake is not recommended for hypertension, as it can lead to cardiovascular issues.
C: Avoiding foods high in potassium is not advised, as potassium helps regulate blood pressure.
D: Consuming alcoholic beverages daily can raise blood pressure and interfere with hypertension management.