Nokea
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.
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When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?
- A. Evaluate the closest proximal pulse.
- B. Observe the color and amount of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess the skin elasticity of the stump.
Correct Answer: A
Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.
A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?
- A. Apply a pressure dressing to the chest tube site.
- B. Administer an oral antihistamine.
- C. Assess the client for allergies to cleaning agents.
- D. Measure the area of swelling and crackling.
Correct Answer: D
Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?
- A. Complete blood count
- B. Lactose tolerance test
- C. Skin allergy testing
- D. Serum immunoglobulin E
Correct Answer: D
Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.
Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?
- A. Fresh fruit and vegetables
- B. Foods sweetened with aspartame
- C. Bread with honey
- D. Gluten-rich bread
Correct Answer: B
Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.
A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?
- A. Assess the child's level of consciousness.
- B. Prepare to administer activated charcoal.
- C. Notify the poison control center.
- D. Obtain an order for serum acetaminophen levels.
Correct Answer: D
Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.