Nokea
A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to check my blood glucose level once a week.
- B. I will limit my carbohydrate intake to 50 grams per day.
- C. I should avoid eating foods high in protein.
- D. I should eat a snack if my blood glucose level is below 200 mg/dL.
Correct Answer: D
Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.
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What is the initial intervention for a patient with chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Provide pain relief
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.
A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?
- A. Limit fluid intake to 2 liters per day.
- B. Increase your intake of whole grains.
- C. Eat 3 large meals daily.
- D. Consume foods high in potassium.
Correct Answer: B
Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.
What is the best position for a patient in respiratory distress?
- A. Semi-Fowler's position
- B. Trendelenburg position
- C. Prone position
- D. Supine position
Correct Answer: A
Rationale: The best position for a patient in respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and eases breathing by allowing the chest to expand more fully. The Trendelenburg position (choice B) where the patient's feet are higher than the head is not recommended in respiratory distress as it may cause increased pressure on the chest and reduced lung expansion. The prone position (choice C) lying on the stomach is also not optimal for respiratory distress as it can further compromise breathing. The supine position (choice D) lying flat on the back is not ideal as it may impair breathing by restricting chest expansion.
What is the primary action when caring for a patient with a stage 3 pressure ulcer?
- A. Apply a hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Apply moist gauze to the ulcer
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.
A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
- A. Eat salty foods to stimulate salivation.
- B. Avoid spicy foods.
- C. Increase intake of high-fiber foods.
- D. Consume cold foods to soothe the mucosa.
Correct Answer: D
Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.