Nokea
A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I should avoid drinking alcohol to prevent irritation of my ulcer.'
- B. 'I should take my antacids regularly, even if I don't have symptoms.'
- C. 'I should avoid eating spicy foods to prevent irritation of my ulcer.'
- D. 'I should limit my caffeine intake to prevent irritation of my ulcer.'
Correct Answer: B
Rationale: The statement 'I should take my antacids regularly, even if I don't have symptoms' indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.
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Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?
- A. Distal pulse intensity
- B. Skin integrity
- C. Pain levels
- D. Range of motion
Correct Answer: A
Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.
A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Instruct the client to rest until the oxygen saturation improves.
- C. Discontinue ambulation and return the client to bed.
- D. Encourage the client to breathe more deeply.
Correct Answer: C
Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.
Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?
- A. I should increase my intake of foods high in calcium.
- B. I should avoid foods with high sodium content.
- C. I need to decrease my intake of vitamin D.
- D. I should consume more potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.
A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct Answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.
A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Increased abdominal girth
Correct Answer: B
Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.