Nokea
A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?
- A. Decrease potassium intake
- B. Increase fluid intake to 2 liters per day
- C. Avoid foods high in calcium
- D. Increase sodium intake
Correct Answer: B
Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.
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A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?
- A. I will soak my feet in hot water every day
- B. I will wear cotton socks at all times
- C. I will cut my toenails in a rounded shape
- D. I will apply lotion between my toes after bathing
Correct Answer: B
Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.
During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct Answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.
A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased white blood cell count
- C. Increased hematocrit
- D. Decreased white blood cell count
Correct Answer: C
Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.
A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?
- A. Decreased hematocrit
- B. Increased heart rate
- C. Increased blood pressure
- D. Decreased respiratory rate
Correct Answer: B
Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.
A nurse is monitoring a client who is receiving continuous enteral feedings. What is a sign of intolerance to the feeding?
- A. Weight gain
- B. Nausea
- C. Constipation
- D. Decreased heart rate
Correct Answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain (Choice A) is not typically a sign of intolerance to enteral feedings but may indicate other health issues. Constipation (Choice C) is not a common sign of feeding intolerance. Decreased heart rate (Choice D) is not typically associated with intolerance to enteral feedings.