Nokea
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?
- A. Boiled rice
- B. Italian bread
- C. Broiled salmon filet
- D. Pickled beets
Correct Answer: D
Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.
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When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?
- A. Blood pressure of 90/60 mm Hg
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Urine output of 30 mL per hour
Correct Answer: A
Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.
A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:
- A. Visitors must wear a mask and a gown
- B. There are no special requirements for visitors of clients on contact precautions
- C. Visitors should wash their hands before and after touching the client
- D. Visitors -
Correct Answer: C
Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.
A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?
- A. A heart rate of 72 beats per minute
- B. A blood pressure of 110/70 mm Hg
- C. Pupils equal and reactive to light
- D. Client reports headache
Correct Answer: C
Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.
A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct Answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.