Nokea
Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: Mashed potatoes and broiled chicken are low in sodium, unlike ham, olives, or bouillon.
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Which of the following statement is NOT true about delegation in nursing?
- A. Assigning tasks
- B. Retains accountability
- C. Only to doctors
- D. Follows scope
Correct Answer: C
Rationale: Delegation assigns tasks (A), retains accountability (B), follows scope (D) 'only to doctors' (C) isn't true, includes aides, per standards. C's restriction misstates delegation's range, like to Mr. Gary's team, making it untrue.
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents these findings as:
- A. Tachypnea
- B. Hyperpyrexia
- C. Arrhythmia
- D. Tachycardia
Correct Answer: D
Rationale: Tachycardia is an elevated heart rate; tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is irregular rhythm.
Which of the following statement is NOT true about wellness?
- A. A dynamic process
- B. Focuses on optimal function
- C. Same with health
- D. Requires balance
Correct Answer: C
Rationale: Wellness is dynamic (A), optimal function-focused (B), balanced (D) not same as health (C), per theory. Wellness is proactive, health a state. C's identity is untrue, making it the correct false statement.
What is the term used for a high-pitched musical sound in clients during a respiratory assessment?
- A. Crowing
- B. Wheezing
- C. Stridor
- D. Sigh
Correct Answer: B
Rationale: A high-pitched musical sound during breathing is wheezing, caused by air passing through narrowed airways, often due to asthma, allergies, or obstruction. Stridor is a harsh, high-pitched sound from upper airway obstruction, distinct from wheezing's expiratory nature. Crowing resembles a rooster's call, linked to laryngospasm, not a musical tone. A sigh is a deep breath, not pathological. Wheezing's recognition guides interventions like bronchodilators, addressing underlying inflammation or constriction, crucial for restoring normal respiration and preventing hypoxia.