Nokea
Among the following statements, which should be given the HIGHEST priority?
- A. Client is in extreme pain
- B. Client's blood pressure is 60/40
- C. Client's temperature is 40 deg. Centigrade
- D. Client is cyanotic
Correct Answer: B
Rationale: BP 60/40 (B) is highest priority; severe hypotension threatens perfusion, per ABCs (circulation). Pain (A), fever (C), and cyanosis (D) are urgent but secondary to life-threatening shock. B demands immediate action, making it correct.
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A client with hyperkalemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of potassium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of sodium-rich foods.
Correct Answer: B
Rationale: Correct! Hyperkalemia is a condition characterized by high levels of potassium in the blood. To manage hyperkalemia, it is essential to decrease the intake of potassium-rich foods since excess potassium can worsen the condition. By understanding the need to decrease potassium-rich foods, the client shows comprehension of the dietary management required for hyperkalemia. Choice A is incorrect because increasing potassium-rich foods would exacerbate hyperkalemia. Choice C is incorrect since increasing sodium-rich foods is unrelated to managing hyperkalemia and could potentially lead to other health issues. Choice D is incorrect as decreasing sodium-rich foods is not the primary focus when managing hyperkalemia.
A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30°
- B. Flush the tube with 50 mL of water every 2 hours
- C. Replace the feeding bag and tubing every 72 hours
- D. Check the client's gastric residual every 8 hours
Correct Answer: A
Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.
Which of the following statement best describe subjective data?
- A. Measurable by the nurse
- B. Reported by the client
- C. Always accurate
- D. A physical finding
Correct Answer: B
Rationale: Subjective data is reported by the client (B), per assessment e.g., pain level. Not measurable (A), not always accurate (C), not physical (D) client-based. B best defines subjective's source, making it correct.
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
- A. High
- B. Low
- C. At the low end of the normal range
- D. At the high end of the normal range
Correct Answer: D
Rationale: Tympanic temp of 37.9°C is normal (36.6-38°C) e.g., high-normal from cough stress. Not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this e.g., monitor trends in acute cases, per standard ranges.
A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?
- A. I should increase my intake of dairy products.
- B. I should decrease my intake of dairy products.
- C. I should increase my intake of high-fiber foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: B
Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.