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A male client with HIV receiving saquinavir PO in combination with other antiretrovirals reports constant hunger and thirst but is losing weight. What action should the nurse implement?
- A. Use a glucometer to check glucose level.
- B. Teach client to measure weight accurately.
- C. Explain that medication dose may need to be increased.
- D. Reassure client weight will increase as viral load decreases.
Correct Answer: A
Rationale: The correct action for the nurse to implement is to use a glucometer to check the client's glucose level. Saquinavir, an HIV medication, can lead to hyperglycemia, which may cause symptoms like constant hunger and thirst while losing weight. Checking the glucose level will help assess for hyperglycemia. Choice B is not the priority in this situation as the client's weight loss is a concerning symptom that needs immediate attention. Choice C is incorrect because increasing the medication dose without assessing the glucose level first could exacerbate hyperglycemia. Choice D is incorrect as it does not address the symptoms of constant hunger, thirst, and weight loss, which may indicate a more urgent issue like hyperglycemia.
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When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Yogurt, milk, and pudding
- B. Tea, lentils, and potato soup
- C. Ice cream, broth, and fruit smoothies
- D. Orange juice, mashed potatoes, and soft cheese
Correct Answer: A
Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.
A client has burns covering 40% of their total body surface area (TBSA). What is the nurse's priority action?
- A. Monitor the client's urinary output hourly.
- B. Apply cool, moist dressings to the burned areas.
- C. Administer pain medication to reduce discomfort.
- D. Administer IV fluids to prevent hypovolemia.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.
When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?
- A. To reduce abdominal pressure on the diaphragm
- B. To promote oxygenation by improving lung expansion
- C. To encourage use of accessory muscles for breathing
- D. To drain secretions and prevent aspiration
Correct Answer: D
Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.
A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?
- A. Check the client's blood pressure.
- B. Assess for signs of bleeding.
- C. Assess the client's neurological status.
- D. Monitor the client's intake and output.
Correct Answer: B
Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.
A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?
- A. Limit sodium intake to reduce fluid retention
- B. Consume high-protein foods to strengthen the heart
- C. Increase potassium intake to manage blood pressure
- D. Increase fluid intake to promote hydration
Correct Answer: A
Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.