Nokea
A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?
- A. Limit sodium intake to 2 grams per day
- B. Increase fluid intake to 2 liters per day
- C. Avoid potassium-rich foods
- D. Avoid alcohol consumption
Correct Answer: B
Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.
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A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?
- A. Decreased heart rate
- B. Nausea
- C. Fever
- D. Weight gain
Correct Answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.
A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?
- A. Bladder distention
- B. Bladder spasms
- C. Hematuria
- D. Increased urine output
Correct Answer: A
Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the IV line
- C. Apply a cold compress
- D. Elevate the limb
Correct Answer: B
Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.
During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct Answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.
A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the IV infusion
- C. Apply a cold compress
- D. Increase the IV flow rate
Correct Answer: B
Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.