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A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." This statement indicates an understanding of the teaching because tight clothing can falsely elevate blood pressure readings. Removing constrictive clothing ensures accurate blood pressure measurement.
Choice A is incorrect because waiting after coffee intake is not directly related to proper blood pressure measurement. Choice B is incorrect as elevating the arm above the heart can lead to inaccurate readings. Choice D is incorrect as measuring blood pressure immediately after eating can also provide inaccurate results due to digestion processes affecting blood pressure.
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A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
- A. Do you receive Holy Communion?
- B. Do you follow a kosher diet?
- C. Do you consume pork products?
- D. Do you oppose receiving a blood transfusion if necessary?
Correct Answer: C
Rationale: The correct answer is C: Do you consume pork products? This question is relevant for a client practicing Islam as pork consumption is prohibited in Islam. Asking about pork consumption helps the nurse understand and respect the client's religious beliefs.
Incorrect answers:
A: Do you receive Holy Communion? - This question is related to Christian practices, not Islam.
B: Do you follow a kosher diet? - This question is related to Jewish dietary laws, not specific to Islam.
D: Do you oppose receiving a blood transfusion if necessary? - While some religious beliefs may affect views on blood transfusions, this question does not specifically address Islamic beliefs.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications.
- B. Educating clients about contraindications to specific immunizations.
- C. Helping clients understand health screenings covered by their insurance plans.
- D. Providing clients with information about the benefits of exercise.
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and minimizing the impact of a disease or condition to prevent complications or further deterioration. By reminding clients to take their medications, the nurse is helping to prevent disease progression and improve health outcomes.
Choice B, educating clients about contraindications to specific immunizations, is an example of secondary prevention as it aims to detect and treat a disease early to prevent complications.
Choice C, helping clients understand health screenings covered by their insurance plans, is an example of primary prevention as it aims to prevent the onset of a disease or condition.
Choice D, providing clients with information about the benefits of exercise, is also an example of primary prevention as it focuses on promoting overall health and preventing the development of diseases.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure.
- B. Instruct the client to avoid coughing during the procedure.
- C. Inform the client that he will be NPO for 6 hr prior to the procedure.
- D. Place the client in the prone position during the procedure.
Correct Answer: B
Rationale: Correct Answer: B - Instruct the client to avoid coughing during the procedure.
Rationale: Coughing during thoracentesis can increase the risk of complications such as lung puncture or bleeding. Instructing the client to avoid coughing helps maintain safety during the procedure by minimizing these risks.
Incorrect Choices:
A: Positioning the client on the affected side for 4 hours following the procedure is not necessary and may not be beneficial. It does not directly impact the safety or success of the thoracentesis.
C: NPO for 6 hours prior to the procedure is not typically required for a thoracentesis. This action is more common for procedures involving anesthesia or sedation.
D: Placing the client in the prone position during the procedure is not recommended for thoracentesis. The client is usually positioned upright or slightly leaning forward to facilitate the procedure.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.
A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?'
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response acknowledges the client's feelings and initiates a discussion about the potential impact of retirement on their well-being. It shows empathy and encourages open communication, allowing the nurse to explore the client's concerns and fears about retirement. This approach promotes client-centered care and helps the nurse understand the client's perspective better.
Choices A, B, and D are incorrect because they do not address the client's feelings or concerns directly. Option A assumes the client's main motivation for retirement is to spend time with family, which may not be the case. Option B and D provide suggestions without first understanding the client's thoughts and emotions, potentially dismissing their feelings. It is essential to prioritize the client's autonomy and individual needs in such discussions.