Nokea
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I will limit my portions of meat to 8 ounces.
- B. I will increase my intake of canned vegetables.
- C. I will use canola oil when making salad dressing.
- D. I will drink whole milk with my cereal.
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats. Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake. Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health. Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.
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A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
- A. Lower the client to the floor.
- B. Obtain the client's vital signs.
- C. Loosen the client's restrictive clothing.
- D. Clear items from the client's surrounding are
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (Choice D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (Choice A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (Choice B) and loosening restrictive clothing (Choice C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
- A. Hold breaths about 3 to 5 seconds before exhaling.'
- B. Exhale slowly through pursed lips.'
- C. Position the mouthpiece 2.5 cm (1 in) from the mouth.'
- D. Place hands on the upper abdomen during inhalation.'
Correct Answer: A
Rationale: Correct Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?
- A. Blood pressure 90/50 mm Hg
- B. Oxygen saturation 95%
- C. Heart rate 60/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 90/50 mm Hg. Dopamine is a vasopressor used to increase blood pressure in hypovolemic shock. A low blood pressure reading of 90/50 mm Hg indicates inadequate perfusion, warranting an increase in dopamine dosage to improve cardiac output. Oxygen saturation (B) and respiratory rate (D) are not direct indicators for adjusting dopamine dosage. A heart rate of 60/min (C) may be within normal limits depending on the client's condition.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
- A. 100 mL of red drainage
- B. 75 mL of greenish-yellow drainage
- C. 200 mL of brown drainage
- D. 150 mL of serosanguineous drainage
Correct Answer: A
Rationale: The correct answer is A: 100 mL of red drainage. Red drainage from an NG tube may indicate active bleeding, which is a concerning finding post-abdominal surgery. This could suggest a potential internal bleeding or vascular injury. The nurse should report this finding to the provider immediately for further evaluation and intervention.
The other choices are incorrect because:
B: 75 mL of greenish-yellow drainage - This could be indicative of bile drainage, which is expected after abdominal surgery.
C: 200 mL of brown drainage - Brown drainage is likely due to old blood or bile, which can be normal in the immediate postoperative period.
D: 150 mL of serosanguineous drainage - Serosanguineous drainage is a mixture of blood and clear fluid, which can be expected after surgery.
Therefore, the correct answer is A due to the potential seriousness of active bleeding indicated by red drainage.