Nokea
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.
You may also like to solve these questions
The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply.
- A. Urinary incontinence
- B. Pupil dilation
- C. Diarrhea
- D. Altered level of consciousness (LOC)
- E. Constipation
Correct Answer: D,E
Rationale: Hydromorphone, an opioid, can cause altered level of consciousness and constipation. Urinary incontinence, pupil dilation, and diarrhea are not typical side effects.
The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations?
- A. Oxygen demand by the muscle exceeds the supply
- B. Oxygen demand and supply of the working muscle are in balance
- C. Oxygen supply exceeds the demand of the working muscle
- D. Oxygen is absent
Correct Answer: A
Rationale: Claudication in PVD results from insufficient blood flow to muscles during activity, causing oxygen demand to exceed supply, leading to pain. Nursing care should aim to improve blood flow (e.g., through exercise programs or medications) and avoid situations where muscle oxygen demand outstrips supply. Balanced or excess supply is desirable, and complete oxygen absence is not typical in claudication.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse take next?
- A. Press the emergency alarm to call the resuscitation team.
- B. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.
- C. Have all visitors and family leave the room.
- D. Call the surgeon to come to the client's room immediately.
Correct Answer: B
Rationale: Covering exposed intestines with sterile, moist dressings prevents infection and drying of tissues, stabilizing the situation until surgical intervention. This is the immediate priority.
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
- A. Hematocrit.
- B. Partial thromboplastin time.
- C. Hemoglobin concentration.
- D. Prothrombin time.
Correct Answer: A
Rationale: Epoetin (Epogen) stimulates red blood cell production and is used to treat anemia. The nurse should assess hematocrit before administration to evaluate the client's response to therapy and ensure levels do not rise excessively, which can increase the risk of hypertension or thrombosis. Hemoglobin is also relevant but hematocrit is more commonly monitored. Coagulation times are not directly affected by epoetin.