A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. ½ cup of canned baked beans
Correct Answer: C
Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.
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A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct Answer: D
Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.
A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I can expect swelling in my hands and on my face.
- B. The amount of protein in my blood is high.
- C. I might have some pain and gas in my stomach from this condition.
- D. I will use a soft bristle toothbrush to prevent bleeding gums.
Correct Answer: A
Rationale: The correct answer is A. Nephrotic syndrome leads to edema, especially of the face and dependent areas, due to the loss of protein in the urine. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is incorrect as using a soft bristle toothbrush is not directly related to the manifestations of nephrotic syndrome.
A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?
- A. Gentle bubbling in the suction chamber
- B. Crepitus around the insertion site
- C. Constant bubbling in the water seal chamber
- D. Absence of breath sounds on the right side
Correct Answer: A
Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.
A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?
- A. Yogurt
- B. Apples
- C. Raisins
- D. Cheddar cheese
Correct Answer: C
Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, making them beneficial for a client at high risk for iron deficiency anemia. Yogurt (Choice A), apples (Choice B), and cheddar cheese (Choice D) are not significant sources of iron. Other iron-rich foods include dried fruits, red meat, and green leafy vegetables.
A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
- B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
- C. I'm so upset that this happened to me. What did I do to deserve this?
- D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.
Correct Answer: A
Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.