Nokea
A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?
- A. Increase protein intake.
- B. Limit fluid intake to 1500 mL/day.
- C. Consume a low-sodium diet.
- D. Take a daily multivitamin.
Correct Answer: C
Rationale: The correct answer is C: Consume a low-sodium diet. Ascites in cirrhosis is often due to fluid retention caused by impaired liver function. A low-sodium diet helps to reduce fluid buildup in the body, alleviating ascites. Increasing protein intake (A) may worsen ascites by increasing fluid retention. Limiting fluid intake (B) can lead to dehydration, exacerbating the condition. Taking a daily multivitamin (D) may be beneficial for overall health but does not directly address ascites.
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A client calls to report redness to the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first?
- A. Please call your doctor.'
- B. Apply a cool compress to your eyes.'
- C. If you are wearing contact lenses, remove them.'
- D. Take an over-the-counter antihistamine.'
Correct Answer: C
Rationale: Removing contact lenses is the first step to prevent further irritation and allow proper assessment of the eye condition.
What factor would be most important to include in Wendy’s discharge teaching plan?
- A. Effective breathing and coughing techniques
- B. Scheduling of return follow-up visits
- C. Program of recommended and contraindicated activities
- D. Individualized measures to prevent future attacks
Correct Answer: D
Rationale: Preventive measures reduce the likelihood of recurrent attacks.
What is the best answer that describes a mechanical defense in a client?
- A. Enzymes
- B. Antibodies
- C. Skin and mucous membranes
- D. Secretions
Correct Answer: C
Rationale: The correct answer is C because skin and mucous membranes act as physical barriers to prevent pathogen entry.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?
- A. Bring a list of all medications and their purposes.
- B. Keep the doctor's phone number close by.
- C. Ensure all providers wash their hands before entering the room.
- D. Document the name of each caregiver who enters the room.
Correct Answer: A
Rationale: The correct answer is A: Bring a list of all medications and their purposes. This is important as it helps prevent medication errors during the surgical procedure. By having a list of medications and their purposes, the healthcare team can ensure they are administering the correct medications and dosages. This also helps in preventing drug interactions or allergies.
Option B (Keep the doctor's phone number close by) may be helpful in case of emergencies, but it does not directly address preventing errors during the surgical procedure. Option C (Ensure all providers wash their hands before entering the room) is important for infection control but is not specifically related to preventing errors. Option D (Document the name of each caregiver who enters the room) is not as critical as having a list of medications, as it does not directly impact the safety and well-being of the client during the surgical procedure.
A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like information about advance directives?
- B. I will arrange for a psychiatrist to speak with you.
- C. Do you want to come off the transplant list?
- D. Would you like to speak with a priest or chaplain?
Correct Answer: A
Rationale: The correct answer is A: Would you like information about advance directives? This is the appropriate response as it addresses the client's concerns about becoming a vegetable and explores their wishes for end-of-life care. Advance directives can help the client make decisions about their care in case they are unable to communicate in the future. The other choices are incorrect because B assumes the client needs psychiatric evaluation, C suggests removing them from the transplant list without exploring their concerns further, and D focuses on spiritual support rather than addressing the client's specific worries about their quality of life post-transplant.