Nokea
A client with hypertension is being taught about the DASH diet. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of sodium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of fruits and vegetables.
- D. I should decrease my intake of whole grains.
Correct Answer: C
Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.
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The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:
- A. Record the heart rate and call the physician
- B. Record the heart rate and administer the medication
- C. Administer the medication and recheck the heart rate in 15 minutes
- D. Hold the medication and recheck the heart rate in 30 minutes
Correct Answer: B
Rationale: For a 6-month-old, an apical pulse of 100 beats per minute falls within the normal range (80-150 bpm), indicating it's safe to administer digoxin, a cardiac glycoside for heart defects, without delay. Recording and calling the physician or holding the dose isn't warranted unless the rate drops below 90-100 bpm (per pediatric guidelines). Rechecking post-administration isn't standard unless symptoms arise. Nurses document and proceed, ensuring timely therapy while monitoring for toxicity signs like bradycardia later.
Indicate true or false: (Adapted: Which statement is true about IV solutions?)
- A. Hypotonic solutions should be replaced intracellular fluid loss.
- B. Smaller veins are ideal for intravenous solutions that are irritating.
- C. Both statements are true.
- D. Neither statement is true.
Correct Answer: A
Rationale: Hypotonic solutions (e.g., 0.45% saline) shift fluid into cells, replacing intracellular loss (e.g., dehydration), making this true ideal for cellular rehydration. Smaller veins aren't ideal for irritating solutions (e.g., potassium); larger veins dilute and tolerate them better, reducing phlebitis making this false. Adapting the true/false format, 'hypotonic solutions should replace intracellular loss' stands as true, supported by fluid dynamics in nursing. Both being true fails due to the vein statement. Neither true ignores the hypotonic role. The first statement's accuracy aligns with IV therapy principles, guiding nurses in fluid management, making it the correct choice.
When reading an autopsy report, the nurse encounters the term 'midsagittal plane.' This nurse understands that this means the body was viewed using a plane that matched which of the following descriptions?
- A. This plane cuts the body horizontally.
- B. This plane divides the body into front and back portions.
- C. The body is separated into left and right equal portions.
- D. The body is divided using an X across the chest.
Correct Answer: C
Rationale: Midsagittal plane splits the body into equal left-right halves, unlike horizontal, front-back, or X divisions. Nurses use this in anatomical understanding.
A patient about to undergo abdominal inspection is best placed in which of the following positions?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Supine allows full abdominal exposure for inspection.
The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?
- A. Provide education about accident prevention
- B. Screen all clients for hypertension
- C. Refer clients with chronic conditions to a specialist
- D. Teach clients with diabetes about a diabetic diet
Correct Answer: A
Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.