A healthcare professional is planning care for a client who has a new prescription for a low-sodium diet. Which of the following foods should the healthcare professional recommend?
- A. Canned soup
- B. Fresh fruit
- C. Pickles
- D. Soy sauce
Correct Answer: B
Rationale: Fresh fruit is naturally low in sodium and is a suitable choice for a low-sodium diet. It provides essential nutrients without adding significant amounts of sodium, making it a healthy option for individuals following a low-sodium diet. Canned soup, pickles, and soy sauce are high in sodium content and should be avoided by individuals on a low-sodium diet. Canned soups are often loaded with added salt, pickles are preserved in brine containing high sodium levels, and soy sauce is a condiment with a high sodium content.
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A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct Answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.
On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which of the following methods would you teach the family to use for removing dust?
- A. Use a damp cloth to remove the dust.
- B. Use a feather duster to remove dust.
- C. Vacuum up the dust.
- D. Use a broom covered with a cloth.
Correct Answer: A
Rationale: Teaching the family to use a damp cloth removes dust effectively, trapping particles rather than dispersing them, unlike feather dusters or brooms. Vacuuming works but isn't always practical for small areas. This method reduces allergens and infection risks in the home, a simple, accessible nursing intervention for environmental hygiene.
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
- A. High
- B. Low
- C. At the low end of the normal range
- D. At the high end of the normal range
Correct Answer: D
Rationale: Tympanic temp of 37.9°C is normal (36.6-38°C) e.g., high-normal from cough stress. Not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this e.g., monitor trends in acute cases, per standard ranges.
Select the 4 findings that require immediate follow-up.
- A. Lung sounds
- B. Capillary refill
- C. Client orientation
- D. Radial pulse characteristic
Correct Answer: D
Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.
Which of the following statement is TRUE about patient's bill of rights?
- A. The client can leave anytime he wants even against medical advice
- B. The client has no right to refuse treatment
- C. The hospital can deny treatment in emergency cases
- D. The client has the right to considerate care only from nurses
Correct Answer: A
Rationale: The client can leave anytime, even against medical advice (A), per autonomy in the bill of rights AMA discharge is legal. No right to refuse (B) is false, hospitals can't deny emergencies (C) per EMTALA, considerate care isn't nurse-only (D). A upholds patient choice, making it true.