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A nurse is assisting with teaching a client who is on a low potassium diet. Which of the following instructions should the nurse include?
- A. Choose orange juice instead of apple juice.
- B. Replace sugar with molasses when baking.
- C. Eat granola for breakfast.
- D. Avoid using salt substitutes when cooking.
Correct Answer: D
Rationale: Salt substitutes contain potassium chloride, increasing potassium intake, which should be avoided.
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A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?
- A. Ground beef
- B. Raw vegetables
- C. Fruit with the skin
- D. High-fiber cereals
Correct Answer: A
Rationale: Ground beef is soft and easy to chew, suitable for a soft diet.
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.
A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?
- A. Vitamin E
- B. Vitamin A
- C. Vitamin C
- D. Vitamin D
Correct Answer: C
Rationale: Vitamin C is water-soluble, requiring regular intake as it's not stored in the body.
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?
- A. Hold your breath for 7 seconds when using the incentive spirometer.
- B. Sit up at a 30-degree angle when using the incentive spirometer.
- C. Use the incentive spirometer once every 4 hours.
- D. Inhale through the incentive spirometer 10 times with each use.
Correct Answer: A
Rationale: Holding breath for up to 7 seconds maximizes lung expansion, a key goal of incentive spirometry.