Nokea
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?
- A. Canola oil
- B. Swiss cheese
- C. Avocados
- D. Walnuts
- E. Olive oil
- F. Fatty fish
- G. Whole grains
Correct Answer: B
Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.
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A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?
- A. Palpate the client's brachial pulses and compare bilaterally.
- B. Check for jugular vein distention while the client is supine.
- C. Check the client's blood pressure while the client lies supine, sits, and stands.
- D. Palpate the client's pedal pulses and compare bilaterally.
- E. Monitor respiratory rate.
- F. Check for chest pain.
- G. Assess skin temperature.
Correct Answer: D
Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.
A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include?
- A. Increase milk consumption to make the urine more alkaline.
- B. Urinate before and after sexual intercourse.
- C. Use a vaginal douche once a week.
- D. Empty the bladder at least every 6 hr.
Correct Answer: B
Rationale: Urinating before and after sexual intercourse flushes bacteria from the urethra, a primary UTI prevention strategy, especially in women due to their shorter urethra. Milk consumption may alkalinize urine, but this doesn't prevent infection cranberry juice is more evidence-based, reducing bacterial adhesion. Vaginal douching disrupts normal flora, increasing UTI risk by promoting pathogen growth, contrary to hygiene goals. Emptying the bladder every 6 hours helps, but more frequent voiding (e.g., every 2-3 hours) is ideal; post-coital urination targets the key risk moment. This instruction empowers the client to reduce recurrence, aligns with urologic recommendations, and addresses a common trigger, making it the most effective teaching point.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
- A. Ask the provider for a prescription for a pureed diet.
- B. Have an assistive personnel feed the client.
- C. Obtain a referral for physical therapy.
- D. Apply foam handles to the client's eating utensils.
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Nurses' Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following 3 statements indicate the client understands the instructions? (Iron deficiency anemia)
- A. I should increase green leafy vegetables in my diet
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
- E. The iron supplement might cause ringing in my ears.
- F. I'll take it with milk for better absorption.
- G. I should avoid citrus fruits.
Correct Answer: A,B,D
Rationale: Green leafy vegetables provide iron, black stools are a side effect, and taking it before meals enhances absorption.