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A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Consume a diet that is high in calories. Patients with COPD often have increased energy needs due to the increased work of breathing. Providing a high-calorie diet helps maintain energy levels and prevent weight loss. Choice B is incorrect because adequate hydration is crucial to help thin mucus and make it easier to clear from the airways. Choice C is incorrect as strenuous exercise can exacerbate COPD symptoms; moderate exercise is recommended. Choice D is incorrect because carbohydrates are an essential energy source and reducing intake can lead to increased fatigue in COPD patients.
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A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase the amount of fresh fruits and vegetables I consume.'
- B. I will need to take my clothes to the dry cleaners to sterilize them.'
- C. I will be sure to wear gloves and wash my hands when I change my cat's litter box.'
- D. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
A nurse is caring for a client who has heart failure. Drag words from the choices below to fill
in each blank in the following sentence. The client is at risk for developing _________ and_________
Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A because Cushing's triad consists of hypertension, bradycardia, and irregular respirations. In a client with a traumatic brain injury, increased intracranial pressure can lead to Cushing's triad due to brainstem compression. Option A reflects an increase in blood pressure, which is a key component of Cushing's triad. Choices B, C, and D do not align with the expected findings of Cushing's triad. Choice B indicates a decrease in heart rate, which is contrary to the bradycardia seen in Cushing's triad. Choice C mentions rapid respirations, whereas irregular or shallow respirations are more characteristic. Choice E mentions hypotension, which is not part of Cushing's triad. Therefore, option A is the correct choice as it aligns with the manifestation of hypertension in Cushing's triad.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, Non-essential or contraindicated for the client.
- A. Metoprolol 15 mg IV bolus
- B. Oxygen at 2 L/min via nasal cannula
- C. Draw electrolytes along with Hgb and Hct
- D. Morphine 6 mg IV bolus every 3 hrs as needed for pain
- E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses
- F. Obtain daily weight
Correct Answer: A,B,C,D E, F
Rationale: [1,1,1,1,1,1]
- Metoprolol 15 mg IV bolus: Anticipated for managing hypertension or tachycardia.
- Oxygen at 2 L/min via nasal cannula: Anticipated for hypoxemia.
- Draw electrolytes along with Hgb and Hct: Anticipated for baseline assessment.
- Morphine 6 mg IV bolus every 3 hrs: Anticipated for pain management.
- Nitroglycerin 0.5 mg SL: Not included in the options.
- Obtain daily weight: Important for monitoring fluid status.