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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?
- A. Take the diuretic every day, regardless of weight loss or muscle weakness.
- B. Weigh yourself daily at the same time and report excessive weight loss.
- C. Limit fluid intake while taking the diuretic to reduce fluid retention.
- D. Stop taking the medication when the edema in the lower extremities subsides.
Correct Answer: B
Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.
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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?
- A. Appearance of the skin on the client's legs.
- B. Altered posture and balance during ambulation.
- C. Presence of bilateral femoral pulses.
- D. Signs of old and new ecchymosis.
Correct Answer: A
Rationale: Assessing skin appearance for signs of neuropathy supports hair loss as a diabetes complication.
The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?
- A. Place protective padding between the client and bed rails.
- B. Provide privacy for the client during the event.
- C. Observe the client's behavior during the event.
- D. Record the client's level of consciousness after the event.
Correct Answer: A
Rationale: Padding prevents injury during a seizure, prioritizing client safety over privacy or observation.
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history indudes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?
- A. Decrease consumption of red meat and most seafood.
- B. Replace dietary table salt with salt substitutes.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Wrap joints with elastic bandage when swollen.
Correct Answer: A
Rationale: Reducing purine-rich foods like red meat and seafood lowers uric acid levels, helping manage gouty arthritis, which likely causes the ankle pain.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
- A. Place pillows around the bed rails to provide padding.
- B. Watch the seizure activity and document the time and client movement.
- C. Manually ventilate the client with a bag-valve mask (BVM).
- D. Stop the IV fluids.
- E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
- F. Begin chest compressions.
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
- A. Prepare to administer a glucose, then insulin, then potassium infusion.
- B. Inform the healthcare provider of the need for potassium replacement.
- C. Instruct the client to Increase dally Intake of potassium rich foods.
- D. Change the plan of care to Include hourly urinary output measurements.
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.