Nokea
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
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A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
- A. Latex
- B. Seafood
- C. Bee stings
- D. Peanuts
Correct Answer: A
Rationale: Correct Answer: A (Latex)
Rationale: Latex allergies can lead to severe reactions, including anaphylaxis, if the client comes into contact with latex during IV therapy. It is crucial to inform the charge nurse to ensure alternative materials are used to prevent a life-threatening allergic reaction.
Summary of other choices:
B: Seafood - While seafood allergies are common, they are not directly related to IV therapy unless the IV solution contains seafood-derived components.
C: Bee stings - Bee sting allergies are important but are not directly relevant to IV therapy unless there is a risk of exposure during the procedure.
D: Peanuts - Peanut allergies are significant but do not pose a direct threat during IV therapy unless peanuts are present in the IV solution or equipment.
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet.
- B. Provide the client with a cold drink prior to defecation.
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement in clients with spinal cord injuries by promoting peristalsis and aiding in bowel evacuation. Increasing refined grains (choice A) may not directly address the bowel-training program. Providing a cold drink (choice B) may not have a significant impact on bowel movements. Restricting fluid intake to 1,500 mL per day (choice D) can lead to dehydration and worsen constipation.
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities.
- B. A client who has a hip fracture and a new onset of tachypnea.
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- D. A client who has diabetes mellitus and an HbA1C of 6.8%.
Correct Answer: B
Rationale: The correct answer is B because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.