Nokea
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.
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A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing.
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings.
- D. Discourage the client from coughing during feedings.
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This position helps promote proper swallowing mechanics and reduces the risk of aspiration in clients with dysphagia. Sitting at or below eye level encourages proper head positioning and coordination during swallowing. Choices A and B are incorrect as they do not directly address the physical positioning needed for safe feeding. Choice D is incorrect as coughing during feedings can help prevent aspiration.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, inflammation of the glomeruli causes blood to leak into the urine, resulting in hematuria. This is a classic sign of the condition. Oliguria (A) is decreased urine output, not typically associated with glomerulonephritis. Hypotension (B) is not a common finding as fluid retention is more likely. Weight loss (C) is not a typical symptom, as fluid retention and edema are more common. In summary, hematuria is the hallmark sign of acute glomerulonephritis, distinguishing it from the other choices.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." This statement indicates an understanding of the teaching because tight clothing can falsely elevate blood pressure readings. Removing constrictive clothing ensures accurate blood pressure measurement.
Choice A is incorrect because waiting after coffee intake is not directly related to proper blood pressure measurement. Choice B is incorrect as elevating the arm above the heart can lead to inaccurate readings. Choice D is incorrect as measuring blood pressure immediately after eating can also provide inaccurate results due to digestion processes affecting blood pressure.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure.
- B. Instruct the client to avoid coughing during the procedure.
- C. Inform the client that he will be NPO for 6 hr prior to the procedure.
- D. Place the client in the prone position during the procedure.
Correct Answer: B
Rationale: Correct Answer: B - Instruct the client to avoid coughing during the procedure.
Rationale: Coughing during thoracentesis can increase the risk of complications such as lung puncture or bleeding. Instructing the client to avoid coughing helps maintain safety during the procedure by minimizing these risks.
Incorrect Choices:
A: Positioning the client on the affected side for 4 hours following the procedure is not necessary and may not be beneficial. It does not directly impact the safety or success of the thoracentesis.
C: NPO for 6 hours prior to the procedure is not typically required for a thoracentesis. This action is more common for procedures involving anesthesia or sedation.
D: Placing the client in the prone position during the procedure is not recommended for thoracentesis. The client is usually positioned upright or slightly leaning forward to facilitate the procedure.