Nokea
A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?
- A. BUN 8 mg/dL
- B. Hgb 15 g/dL
- C. Creatinine 0.8 mg/dL
- D. Sodium 140 mEq/L
Correct Answer: A
Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.
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A client is planning eating strategies with a nurse who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?
- A. Encourage the client to eat, even if nauseated.
- B. Provide low-fat carbohydrates with meals.
- C. Limit fluid intake between meals.
- D. Serve hot foods at mealtime.
Correct Answer: B
Rationale: The correct answer is B: Provide low-fat carbohydrates with meals. Low-fat carbohydrates are easier to digest and can help manage nausea without overloading the digestive system. Encouraging the client to eat even if nauseated (Choice A) may worsen their symptoms. Limiting fluid intake between meals (Choice C) may lead to dehydration, which can exacerbate nausea. Serving hot foods at mealtime (Choice D) may not necessarily address the underlying issue of equilibrium imbalance causing nausea.
A client with hypertension is being educated by a nurse about a heart-healthy diet. Which of the following statements indicates that the client understands the teaching?
- A. I will get 15% of my total daily calories from saturated fats.
- B. I will decrease the potassium in my diet.
- C. I will limit my daily sodium intake to 3 grams.
- D. I will eat five 8-ounce servings of fruit daily.
Correct Answer: C
Rationale: The correct answer is C. Limiting daily sodium intake to 3 grams is crucial in managing blood pressure and is a fundamental aspect of a heart-healthy diet. High sodium intake can contribute to hypertension and cardiovascular issues. Choices A, B, and D are incorrect because getting 15% of daily calories from saturated fats, decreasing potassium intake, and eating five servings of fruit do not directly address the management of hypertension through sodium restriction.
A nurse is providing teaching to an obese client who has gestational diabetes and is at 25 weeks of gestation. Which of the following statements made by the client indicates a need for further teaching?
- A. This does not mean that my baby will have this disease.
- B. This means that I will have diabetes for the rest of my life.
- C. If I feel dizzy, I should drink six ounces of a non-diet soda.
- D. Being obese might be one reason why I developed diabetes.
Correct Answer: B
Rationale: The statement 'This means that I will have diabetes for the rest of my life' indicates a need for further teaching. Gestational diabetes often resolves after pregnancy, although it does indicate a higher risk for developing type 2 diabetes in the future. The other choices are correct or provide appropriate information: A) Understanding that gestational diabetes does not mean the baby will have the disease is accurate. C) Advising to drink non-diet soda if feeling dizzy is incorrect and potentially harmful due to the sugar content. D) Recognizing that obesity can be a risk factor for developing diabetes is a valid statement.
A nurse is teaching a client about complete and incomplete proteins. Which of the following foods should the nurse include in the teaching as an incomplete protein?
- A. 4 oz chickpeas
- B. 2 poached eggs
- C. 2 oz cheddar cheese
- D. 4 oz salmon fillet
Correct Answer: A
Rationale: The correct answer is A: 4 oz chickpeas. Chickpeas are considered an incomplete protein because they lack one or more essential amino acids required by the body. Incomplete proteins do not provide all essential amino acids in sufficient quantities. Choice B, 2 poached eggs, is a complete protein source because eggs contain all essential amino acids. Choice C, 2 oz cheddar cheese, is also a complete protein as it contains all essential amino acids. Choice D, 4 oz salmon fillet, is another complete protein source as fish typically provide all essential amino acids needed by the body.
A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?
- A. Check for gastric residual.
- B. Apply low intermittent suction.
- C. Increase the rate of the feeding.
- D. Request a higher-fat formula.
Correct Answer: A
Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.