Nokea
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
- A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
- B. I need to avoid eating proteins, including red meat.
- C. I will limit my intake of beef to 4 ounces per week.
- D. My blood level of low density lipoproteins needs to increase.
Correct Answer: C
Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.
You may also like to solve these questions
After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?
- A. Semi-Fowler's
- B. Prone
- C. Supine
- D. Sim's
Correct Answer: A
Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.
The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?
- A. Dilute each of the medications with sterile water prior to administration.
- B. Mix the medications in one syringe before opening the feeding tube.
- C. Administer water between the doses of the two liquid medications.
- D. Withdraw any fluid from the tube before instilling each medication.
Correct Answer: C
Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.
A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
- A. Document the client's temperature fluctuations
- B. Assess for flushed, warm skin consistently
- C. Measure temperature at regular intervals
- D. Use different sites for temperature measurement
Correct Answer: C
Rationale: To assess fever patterns accurately, the nurse should measure the client's temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.
When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct Answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
After insertion of the indwelling catheter, how should the nurse position the drainage container?
- A. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
- B. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
- C. At the head of the bed for easy and accurate measurement of urine.
- D. Beside the patient in their bed to avoid embarrassment.
Correct Answer: B
Rationale: The correct position for the drainage container after inserting an indwelling catheter is to have it placed lower than the bladder. This positioning helps maintain a constant downward flow of urine from the bladder, preventing backflow and ensuring proper drainage. Choice A is incorrect because having the drainage tubing taut does not promote proper urine flow and may cause kinking. Choice C is incorrect as placing the container at the head of the bed does not affect drainage and is not necessary for accurate measurement. Choice D is incorrect as the positioning of the drainage container should prioritize proper drainage and care over potential embarrassment.