Nokea
The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.
- A. Vitamin K.
- B. Vitamin B6.
- C. Folate.
- D. Vitamin B12.
- E. Vitamin D.
Correct Answer: B, C, D
Rationale: Vitamin B6, folate, and vitamin B12 reduce homocysteine levels, a risk factor for coronary heart disease.
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The current focus of performance improvement activities is to facilitate and address:
- A. Sound structures like policies and procedures
- B. Processes and how they are being done
- C. Optimal client outcomes
- D. Optimal staff performance
Correct Answer: C
Rationale: Performance improvement activities focus on achieving optimal client outcomes by improving the quality and safety of care delivery.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care?
- A. Take apical heart rate after each dose of morphine.
- B. Assess urinary output every 8 hours.
- C. Assess mental status every shift.
- D. Check for pedal edema every 4 hours.
Correct Answer: C
Rationale: Morphine can cause sedation and altered mental status, requiring regular assessment to monitor for adverse effects.
A client with a history of chronic kidney disease is admitted with edema. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypermagnesemia.
- E. Hypophosphatemia.
Correct Answer: A, B, C, D
Rationale: Chronic kidney disease can cause hyperkalemia, hyponatremia, hypocalcemia, and hypermagnesemia due to impaired excretion and filtration.