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A nurse is teaching a client who has hypertension about dietary modifications. Which of the following instructions should the nurse include?
- A. Increase sodium intake
- B. Reduce sodium intake to less than 1,500 mg per day
- C. Limit caffeine intake
- D. Increase caffeine intake to improve focus
Correct Answer: B
Rationale: The correct answer is B: 'Reduce sodium intake to less than 1,500 mg per day.' For clients with hypertension, reducing sodium intake is crucial as it helps manage blood pressure. High sodium intake can lead to fluid retention and increased blood pressure. Choice A is incorrect because increasing sodium intake would worsen hypertension. Choice C is also correct as limiting caffeine intake is beneficial for managing hypertension. Choice D is incorrect as increasing caffeine intake can elevate blood pressure, which is detrimental for clients with hypertension.
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What is the first step in preparing a blood transfusion?
- A. Administer the blood via IV push
- B. Verify the client's blood type before starting the transfusion
- C. Warm the blood to body temperature before administration
- D. Administer diuretics to prevent fluid overload
Correct Answer: B
Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.
A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?
- A. Rectal
- B. Axillary
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.
What is the primary intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct Answer: D
Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?
- A. Encourage deep breathing exercises
- B. Maintain the client in a supine position
- C. Apply a sequential compression device
- D. Massage the client's legs
Correct Answer: C
Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.
A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
- A. I had a bowel movement, but I was able to save the urine.
- B. I have a specimen in the bathroom from about 30 minutes ago.
- C. I flushed what I urinated at 7 am and have saved the rest since.
- D. I drink a lot, so I will fill up the bottle and complete the test quickly.
Correct Answer: C
Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.