Nokea
A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?
- A. Drink carbonated beverages.
- B. Decrease fiber intake.
- C. Use bronchodilators after meals.
- D. Increase protein intake.
Correct Answer: D
Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.
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A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?
- A. I will drink water with my meals.
- B. I will eat every 6 hours throughout the day.
- C. I will eat crackers before I get out of bed in the morning.
- D. I will limit my protein intake.
Correct Answer: C
Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.
After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to suck on ice chips
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.
In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?
- A. Neurological status
- B. Cardiac status
- C. Respiratory status
- D. Gastrointestinal status
Correct Answer: B
Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct Answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.