Nokea
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
- A. Cornflakes, whole milk, banana, and coffee
- B. Scrambled eggs, bacon, toast, and coffee
- C. Oatmeal, apple juice, dry toast, and coffee
- D. Pancakes, ham, tomato juice, and coffee
Correct Answer: C
Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.
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Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
The nurse is assessing a client with a history of heart failure who is receiving furosemide (Lasix). Which of the following findings would indicate a need to withhold the medication?
- A. Potassium level of 2.8 mEq/L.
- B. Blood pressure of 130/80 mmHg.
- C. Heart rate of 80 beats per minute.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: hypokalemia is a side effect of furosemide; a potassium level of 2.8 mEq/L is low and requires intervention before administering the medication
Which of the following is the best indicator of the diagnosis of HIV?
- A. White blood cell count
- B. ELISA
- C. Western Blot
- D. Complete blood count
Correct Answer: C
Rationale: The Western Blot is the most specific test for confirming HIV diagnosis after a positive ELISA.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.