Nokea
The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?
- A. Increase sodium intake.
- B. Engage in regular physical activity.
- C. Avoid foods high in fat.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: B
Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.
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The nurse is caring for a client who is postoperative following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?
- A. Keep the client in a low Fowler's position.
- B. Maintain hip abduction with pillows.
- C. Encourage early ambulation.
- D. Place the client in a prone position.
Correct Answer: B
Rationale: Maintaining hip abduction with pillows is the most important intervention to prevent dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and prevents excessive internal rotation, which can lead to dislocation. Keeping the client in a low Fowler's position (Choice A) does not provide the necessary support and stability for the hip joint. While early ambulation (Choice C) is important for preventing complications such as blood clots and promoting circulation, it is not the most crucial intervention for preventing dislocation. Placing the client in a prone position (Choice D) can be harmful and increase the risk of dislocation.
The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct Answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.
When teaching a diabetic client about foot care, what information is most important?
- A. Inspect feet daily
- B. Wear cotton socks
- C. Use lukewarm water to wash feet
- D. Cut nails straight across
Correct Answer: A
Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.
The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow down the rate of the transfusion
- B. Administer an antipyretic
- C. Stop the transfusion immediately
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.
A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?
- A. Administer pain medication as prescribed
- B. Assess the pain's nature and intensity
- C. Encourage the client to rest and apply a hot pack
- D. Notify the physician immediately
Correct Answer: B
Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.