Nokea
A nurse is providing teaching to a client who has a new diagnosis of hypertension. Which of the following dietary recommendations should the nurse include?
- A. Limit sodium intake to 4 grams per day.
- B. Limit protein intake to 80 grams per day.
- C. Limit saturated fat intake to 7% of daily calories.
- D. Limit fluid intake to 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is to limit saturated fat intake to 7% of daily calories. This recommendation is crucial for clients with hypertension to lower cholesterol levels and promote heart health. Choice A, limiting sodium intake to 4 grams per day, is important for hypertension but not the best recommendation compared to limiting saturated fats. Choice B, limiting protein intake to 80 grams per day, is not a primary dietary concern for hypertension. Choice D, limiting fluid intake to 1,500 mL per day, is not a standard recommendation for hypertension management.
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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. Blood glucose level of 150 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Serum potassium level of 3.0 mEq/L
- D. Serum albumin level of 3.8 g/dL
Correct Answer: C
Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L is below the normal range and indicates hypokalemia, which should be reported to the provider. Hypokalemia can lead to serious complications such as cardiac arrhythmias. Choices A, B, and D are within normal ranges and do not require immediate reporting. A blood glucose level of 150 mg/dL is slightly elevated but not critically high. A serum sodium level of 138 mEq/L is within the normal range. A serum albumin level of 3.8 g/dL is also within the normal range.
A nurse is providing teaching to a client who has type 1 diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Trim your toenails straight across.
- D. Apply lotion to your feet after bathing.
Correct Answer: C
Rationale: The correct answer is C: 'Trim your toenails straight across.' Trimming toenails straight across helps prevent ingrown toenails, which is important for clients with diabetes to prevent infections. Choice A is incorrect because soaking feet in warm water can lead to skin breakdown and infections. Choice B is incorrect as cotton socks can retain moisture, increasing the risk of fungal infections. Choice D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of infections.
A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?
- A. Dry, hacking cough
- B. Bounding peripheral pulses
- C. Decreased urinary output
- D. Weight loss of 1 kg in 24 hours
Correct Answer: C
Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.
What is the most important nursing action when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.
What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?
- A. Respect the patient's decision and notify the provider
- B. Attempt to persuade the patient to accept the transfusion
- C. Document the refusal and notify the healthcare provider
- D. Provide education on the benefits of blood transfusion
Correct Answer: A
Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.