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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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A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
- A. Administer PRN haloperidol (Haldol) to decrease the need to walk
- B. Assess the client's gait for steadiness
- C. Restrain the client in a geriatric chair
- D. Administer PRN lorazepam (Ativan) to provide sedation
Correct Answer: B
Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client with pneumonia who had new onset of confusion
- B. A client with diabetes who had low blood sugar overnight
- C. A client with a leg fracture who needs pain medication
- D. A client whose urinary output was 100 mL for the past 12 hours
Correct Answer: A
Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.
Which of the following is the best intervention for managing dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor fluid and electrolyte levels
- C. Encourage the client to drink more fluids
- D. Administer intravenous fluids
Correct Answer: B
Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?
- A. The child is placed in a private room
- B. The staff removes a toy from the child's bed and takes it to the nurse's station
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
- D. The staff uses standard precautions
Correct Answer: A
Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.