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A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.
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A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
- A. Breathing so rapidly interferes with oxygenation.
- B. Maybe the client has respiratory distress syndrome.
- C. The blood clot interferes with perfusion in the lungs.
- D. The client needs immediate intubation & mechanical ventilation.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. A pulmonary embolism is a blockage in one of the pulmonary arteries, affecting blood flow to the lungs.
2. This blockage limits perfusion, the process of blood flow through the lungs for oxygenation.
3. Oxygen saturation may not improve significantly because the blood clot interferes with perfusion, not ventilation.
4. Options A and B focus on ventilation issues, which may not be the primary concern in this case.
5. Option D is extreme and not supported by the information given about the client's condition.
Summary:
Choice C is correct because a pulmonary embolism affects perfusion in the lungs, leading to decreased oxygen saturation. Choices A, B, and D are incorrect as they focus on other issues not directly related to the client's condition.
On assessment of a patient’s learning needs, the nurse determines that a patient taking potassium-wasting diuretics does not know what foods are high in potassium. What is an appropriate nursing diagnosis for this patient?
- A. Risk for cardiac dysrhythmias related to low potassium intake
- B. Deficient knowledge related to not knowing what foods are high in potassium
- C. Imbalanced nutrition: less than body requirements related to lack of intake of potassium-rich foods
- D. Deficient knowledge related to lack of interest regarding dietary requirements when taking diuretics
Correct Answer: B
Rationale: The correct answer is 'Deficient knowledge related to not knowing what foods are high in potassium.' This nursing diagnosis directly addresses the identified learning need. While other options may be indirectly relevant, the primary issue here is the patient's lack of knowledge about potassium-rich foods.
A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?
- A. I can have clear liquids up to 2 hours before the procedure.
- B. I need to take a laxative the night before the procedure.
- C. I will be sedated during the procedure.
- D. I should avoid eating solid foods for 24 hours before the procedure.
Correct Answer: D
Rationale: The correct answer is D because the statement indicates a need for further teaching. The client should avoid solid foods for a specific period, usually 24 hours, before a colonoscopy to ensure a clear view of the colon. This helps the healthcare provider to perform the procedure effectively and reduces the risk of complications. Choices A, B, and C are incorrect because having clear liquids up to 2 hours before, taking a laxative the night before, and being sedated during the procedure are all standard preparations for a colonoscopy and do not indicate a need for further teaching.
How can a nurse manager best improve hand-off communication among the staff? (SATA)
- A. Attending hand-off rounds to coach and mentor.
- B. Conducting audits of staff using a new template.
- C. Creating a template of topics to include in the report.
- D. Utilizing the SHARE model as a tool for standardizing hand-off reports and other critical communication.
Correct Answer: D
Rationale: The correct answer is D because utilizing the SHARE model helps standardize hand-off reports and communication.
1. S stands for Situation: providing context.
2. H stands for History: outlining relevant information.
3. A stands for Assessment: sharing assessment findings.
4. R stands for Recommendation: suggesting actions.
5. E stands for Explanation: clarifying any questions.
This model ensures all necessary information is communicated effectively. A, B, and C are incorrect because attending hand-off rounds, conducting audits, and creating templates may not ensure standardized communication like the SHARE model does.
What are the priority nursing interventions for a client in shock?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.