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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.
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How should a healthcare professional care for a patient with a central line to prevent infection?
- A. Change the dressing daily
- B. Monitor for redness
- C. Check the central line site every shift
- D. Flush the line with saline
Correct Answer: A
Rationale: Corrected Rationale: Changing the central line dressing daily is crucial in preventing infection at the insertion site. This practice helps maintain a clean and sterile environment around the central line, reducing the risk of pathogens entering the bloodstream. Monitoring for redness (choice B) is important but may not directly prevent infection. Checking the central line site every shift (choice C) is essential for early detection of any issues but does not solely prevent infection. Flushing the line with saline (choice D) is a necessary procedure for maintaining central line patency but does not primarily prevent infection.
A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Weigh the client weekly to monitor for fluid retention.
- B. Monitor the client's blood glucose level every 6 hours.
- C. Change the TPN tubing every 72 hours.
- D. Flush the TPN line with sterile water before and after administration.
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's blood glucose level every 6 hours. When a client is on TPN, it is crucial to monitor their blood glucose levels frequently to prevent complications such as hyperglycemia or hypoglycemia. Weighing the client weekly to monitor for fluid retention (choice A) is important but not as critical as monitoring blood glucose levels. Changing the TPN tubing every 72 hours (choice C) is important for infection control but does not directly relate to the client's metabolic status. Flushing the TPN line with sterile water before and after administration (choice D) is not a standard practice and may introduce contaminants into the TPN solution.
A client is being discharged two days after a mastectomy. Which of the following instructions should the nurse include?
- A. Wear a tight-fitting bra for support.
- B. Avoid lifting heavy objects for at least 6 weeks.
- C. Sleep on the affected side to promote healing.
- D. Begin arm exercises 24 hours after surgery.
Correct Answer: B
Rationale: The correct answer is to instruct the client to avoid lifting heavy objects for at least 6 weeks after a mastectomy. This is important to prevent complications and promote proper healing. Choice A is incorrect because tight-fitting bras can increase the risk of lymphedema and discomfort. Choice C is incorrect as sleeping on the affected side can cause discomfort and interfere with healing. Choice D is incorrect as initiating arm exercises too soon after surgery can strain the surgical site and hinder recovery.
What is the primary purpose of administering an antiemetic?
- A. To reduce nausea and vomiting
- B. To increase appetite
- C. To treat nausea caused by chemotherapy
- D. To treat allergic reactions
Correct Answer: A
Rationale: The correct answer is A: 'To reduce nausea and vomiting.' Antiemetics are medications used to prevent or alleviate nausea and vomiting. While they may indirectly help with appetite by reducing the unpleasant symptoms that can lead to decreased food intake, their primary purpose is not to increase appetite (Choice B). Choice C, 'To treat nausea caused by chemotherapy,' is partly correct as antiemetics are commonly used to manage chemotherapy-induced nausea, but this is not their exclusive purpose. Choice D, 'To treat allergic reactions,' is incorrect as antiemetics are not primarily used for treating allergic reactions.
A client with a new diagnosis of celiac disease is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I can still have oatmeal for breakfast.
- B. I need to avoid foods that contain gluten.
- C. I can have rye toast with my eggs.
- D. I can continue to eat foods made from barley.
Correct Answer: B
Rationale: The correct answer is B because clients with celiac disease should avoid gluten, which is found in foods like rye and barley. Choice A is incorrect because oatmeal may contain gluten unless specified gluten-free. Choice C is incorrect as rye contains gluten. Choice D is incorrect as barley contains gluten.