Nokea
A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?
- A. Peanut butter and jelly sandwich
- B. Grilled chicken and rice
- C. Tomato soup with saltine crackers
- D. Baked fish and steamed vegetables
Correct Answer: D
Rationale: The correct answer is D, baked fish and steamed vegetables. These food choices are low in potassium and phosphorus, which is important for clients with chronic kidney disease to manage their condition effectively. Grilled chicken and rice (choice B) may be high in phosphorus, tomato soup with saltine crackers (choice C) is high in sodium, and a peanut butter and jelly sandwich (choice A) contains high levels of potassium, all of which are not ideal choices for individuals with chronic kidney disease.
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A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself every morning.
- B. I should drink 2 liters of water each day.
- C. I should avoid all physical activity.
- D. I should take an extra dose of diuretic if I gain 2 pounds in a day.
Correct Answer: A
Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.
When teaching a client about nutritional intake, what should be included?
- A. Carbohydrates should be at least 45% of your caloric intake.
- B. Protein should be at least 55% of your caloric intake.
- C. Carbohydrates should be at least 30% of your caloric intake.
- D. Protein should be at least 60% of your caloric intake.
Correct Answer: A
Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.
How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?
- A. Monitor platelet count
- B. Monitor PT/INR
- C. Monitor aPTT
- D. Monitor CBC
Correct Answer: C
Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.
A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
- A. WBC 4,500/mm3
- B. Hemoglobin 12 g/dL
- C. Platelet count 250,000/mm3
- D. Platelet count 100,000/mm3
Correct Answer: D
Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.