Nokea
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
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A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
- A. Monitor for leg cramps.
- B. Increase sodium intake.
- C. Monitor for headache.
- D. Take the medication at bedtime.
Correct Answer: A
Rationale: Rationale: Correct answer is A. Leg cramps are a common side effect of hydrochlorothiazide due to electrolyte imbalance. Monitoring for leg cramps will help in identifying and managing this side effect promptly. Choices B and D are incorrect as hydrochlorothiazide can lead to electrolyte depletion, so increasing sodium intake is not recommended, and taking the medication at bedtime may increase nighttime urination. Choice C is incorrect as headaches are not a common side effect of hydrochlorothiazide.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Pallor and numbness distal to the fistula site
- C. Redness and warmth at the fistula site
- D. Pain in the fistula site
Correct Answer: B
Rationale: The correct answer is B: Pallor and numbness distal to the fistula site. This is indicative of venous insufficiency in a client with an arteriovenous fistula. Venous insufficiency occurs when there is inadequate venous return to the heart, leading to decreased blood flow and oxygen delivery to the tissues. Pallor and numbness are signs of decreased blood flow, which can occur when the fistula is not functioning properly. Cold and numbness (choice A) may indicate arterial insufficiency, not venous. Redness and warmth (choice C) are signs of inflammation, not venous insufficiency. Pain in the fistula site (choice D) may be due to other reasons like infection or nerve compression, not necessarily venous insufficiency.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
A nurse is teaching a client with a history of calcium oxalate kidney stones. What advice should be given?
- A. Limit fluid intake to 1 L per day.
- B. Drink 3 L of fluid every day.
- C. Increase calcium intake.
- D. Avoid all citrus juices.
Correct Answer: B
Rationale: The correct answer is B: Drink 3 L of fluid every day. Increasing fluid intake helps prevent the formation of kidney stones by diluting the urine and reducing the concentration of minerals like calcium oxalate. Adequate hydration promotes frequent urination, which helps flush out these minerals. Limiting fluid intake (choice A) can lead to concentrated urine and increase the risk of stone formation. Increasing calcium intake (choice C) can actually help prevent calcium oxalate stones, as calcium binds with oxalate in the intestines, reducing its absorption. Avoiding all citrus juices (choice D) is unnecessary, as they do not directly contribute to the formation of calcium oxalate stones.