Nokea
A client with a new diagnosis of hypertension is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will limit my saturated fat intake to 7% of daily calories.
- D. I will take my medication only when I have symptoms.
Correct Answer: C
Rationale: The correct answer is C because limiting saturated fat intake to 7% of daily calories is a crucial component of the dietary management for hypertension. This dietary modification helps reduce the risk of cardiovascular complications. Choices A, B, and D are incorrect. Choice A is incorrect because medication adherence should not be based on symptoms like dizziness. Choice B is inadequate as blood pressure monitoring should be more frequent, preferably daily, for effective management of hypertension. Choice D is incorrect because medication for hypertension should be taken consistently as prescribed, not just when symptoms occur.
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A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct Answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
What is the most appropriate action when a patient experiences a fall in the hospital?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is to assess the patient for injuries. When a patient experiences a fall in the hospital, the immediate concern is to check for any injuries that may require urgent care. Calling for help can be done after assessing the patient to ensure appropriate assistance is provided. Documenting the fall is important for the patient's medical record, but it is not the most immediate action needed. Notifying the healthcare provider can come after the initial assessment to update them on the situation.
What is the priority intervention for a patient presenting with chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Reposition the patient
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.
How should a healthcare provider manage a patient with a history of hypertension who is non-compliant with medication?
- A. Educate the patient on the importance of medication
- B. Reassess the patient in 6 months
- C. Refer the patient to a specialist
- D. Discontinue the medication
Correct Answer: A
Rationale: Educating the patient on the importance of medication is crucial when dealing with a patient who is non-compliant with their hypertension medication. By providing information about the significance of the medication in controlling blood pressure and preventing complications, the patient may be more motivated to adhere to the prescribed treatment. Reassessing the patient in 6 months (choice B) may lead to further deterioration of the patient's condition if non-compliance continues. Referring the patient to a specialist (choice C) may be necessary in some cases but should be preceded by efforts to improve compliance. Discontinuing the medication (choice D) without addressing the non-compliance issue can have serious health consequences for the patient.
A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 90/min
- B. Redness and warmth in the calf
- C. Oxygen saturation of 95%
- D. Temperature of 37.3°C (99.1°F)
Correct Answer: B
Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.