Nokea
A nurse is reinforcing dietary teaching with a client who wants to reduce solid fat intake. Which of the following instructions should the nurse include?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier alternative to butter as it is a liquid fat and contains unsaturated fats, which are better for heart health and reducing solid fat intake. Butter, on the other hand, is a solid fat high in saturated fats, which can increase cholesterol levels. This substitution promotes a lower intake of solid fats while still allowing for baking needs. The other choices are incorrect because: A) Stick margarine is also a solid fat high in trans fats, not suitable for reducing solid fat intake. C) Whole milk contains solid fats, so opting for low-fat or skim milk would be better. D) Ground beef with at least 80% lean meat still contains solid fats, so choosing leaner options like 90% lean or ground turkey would be more beneficial.
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A nurse is assisting a client in planning an exercise routine. Which of the following activities should the nurse encourage the client to avoid due to age-related changes?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Age-related changes such as decreased bone density and joint stiffness can make running high-impact and potentially harmful. Stretching (A) is important for flexibility, resistance training (C) helps maintain muscle mass, and aerobic exercises (D) improve cardiovascular health. Running may exacerbate joint issues.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
- A. Crackles
- B. Rhonchi
- C. Stridor
- D. Wheezes
Correct Answer: D
Rationale: Wheezes are high-pitched musical sounds heard on expiration and indicate narrowed airways, commonly found in asthma patients.
A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The correct answer is A: Metabolic acidosis. The pH is low (acidosis) and the HCO3- is also low, indicating a primary metabolic acidosis. The low PaCO2 (respiratory alkalosis compensation) further supports metabolic acidosis. Other choices are incorrect because B: Respiratory acidosis would have a high PaCO2, C: Metabolic alkalosis would have a high HCO3-, and D: Respiratory alkalosis would have a low PaCO2 with a high pH.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.
A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?
- A. Over articulate words to improve client understanding.
- B. Change voice volume during each sentence.
- C. Minimize background noise to decrease distractions.
- D. Sit in a chair to one side of the client.
Correct Answer: C
Rationale: Minimizing background noise enhances communication for clients with hearing loss.