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A low-sodium diet has been ordered for an adult client. The nurse knows that the client understands his low-sodium diet when the client selects which menu?
- A. Tossed salad, carrot sticks, and steak
- B. Baked chicken, mashed potatoes, and green beans
- C. Hot dog, roll, and coleslaw
- D. Chicken noodle soup, applesauce, and cottage cheese
Correct Answer: B
Rationale: Baked chicken, mashed potatoes, and green beans are naturally low in sodium. Steak, hot dogs, and chicken noodle soup are typically high in sodium.
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An adult male is being evaluated for possible dysrhythmia and is to be placed on a Holter monitor. What instructions should the nurse give him to ensure that this test provides a comprehensive picture of his cardiac status?
- A. Remove the electrodes intermittently for hygiene measures.
- B. Exercise frequently while the monitor is in place.
- C. Keep a diary of all your activities while being monitored.
- D. Refrain from activities that precipitate symptoms.
Correct Answer: C
Rationale: Keeping a diary of activities correlates symptoms or dysrhythmias with specific triggers, providing a comprehensive picture for diagnosis.
Which response by the nurse is most appropriate at this time?
- A. What are your concerns?
- B. Why are you so scared?
- C. Your doctor says you are doing just fine.
- D. You need to concentrate on getting well.
Correct Answer: A
Rationale: Asking about concerns encourages the client to express fears, facilitating emotional support and reducing anxiety.
Which statement is the best indication that the client understands the surgical procedure involving mitral valve replacement?
- A. My blood will be circulated through a heart-lung machine.
- B. The surgeon will enlarge my valve by inserting a stent.
- C. My blood will be opened during surgery, but my heart will not.
- D. A piece of my leg vein will be used to replace the diseased valve.
Correct Answer: A
Rationale: Mitral valve replacement requires a heart-lung machine for cardiopulmonary bypass.
Avoiding which of the following foods is the best evidence that the client understands the nurse's dietary instructions?
- A. Pepperoni pizza
- B. Vinegar and oil salad dressing
- C. Liver and onions
- D. Lemon-pepper chicken
Correct Answer: A
Rationale: Pepperoni pizza is high in fat and sodium, which should be avoided in a low-fat, low-sodium diet post-MI.
The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. Which instructions should be included? Select all that apply.
- A. Take a shower rather than a tub bath until the puncture site heals.
- B. Perform leg exercises every 2 hours while awake.
- C. In the generous amount of fluids for the next 24 hours.
- D. Report worsening of pain in the leg that was catheterized.
- E. Flush the toilet twice after eliminating urine and stool in the next 24 hours.
- F. Change the dressing over the puncture site daily until it heals.
Correct Answer: A,C,D
Rationale: Showering prevents infection, generous fluids help flush contrast dye, and reporting worsening pain detects complications. Leg exercises, double flushing, and daily dressing changes are not standard.