Nokea
The nurse is providing care for a client with a chest tube. If the chest tube becomes disconnected from the drainage system, the nurse should:
- A. Secure the chest tube with tape and notify the physician
- B. Clamp the chest tube near the insertion site
- C. Submerge the end of the tube in sterile water
- D. Insert the tube into the drainage system without cleansing
Correct Answer: C
Rationale: Submerging the chest tube end in sterile water creates a water seal, preventing pneumothorax if disconnected taping delays, clamping risks tension pneumothorax, and reinserting uncleaned spreads infection. Nurses act quickly, ensuring lung re-expansion, critical in chest tube care.
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A client with chronic kidney disease is being educated by a nurse about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should limit my intake of protein to prevent overworking my kidneys.
- B. I should increase my intake of potassium-rich foods.
- C. I should increase my intake of phosphorus-rich foods.
- D. I should increase my intake of calcium-rich foods.
Correct Answer: A
Rationale: The correct answer is A. In chronic kidney disease, limiting protein intake is crucial to prevent overworking the kidneys. Excessive protein consumption can lead to the accumulation of metabolic waste products that the kidneys struggle to process, worsening kidney function. Therefore, by recognizing the need to restrict protein intake, the client demonstrates an understanding of the dietary management required for their condition. Choices B, C, and D are incorrect. Increasing intake of potassium-rich foods (Choice B) is not recommended in chronic kidney disease as it can lead to hyperkalemia. Similarly, increasing intake of phosphorus-rich foods (Choice C) is not advised because impaired kidneys struggle to excrete phosphorus, leading to elevated levels in the blood. Lastly, increasing intake of calcium-rich foods (Choice D) may not be necessary unless there is a specific deficiency or requirement, as calcium balance is often disrupted in chronic kidney disease.
A client with hyperkalemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of potassium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of sodium-rich foods.
Correct Answer: B
Rationale: Correct! Hyperkalemia is a condition characterized by high levels of potassium in the blood. To manage hyperkalemia, it is essential to decrease the intake of potassium-rich foods since excess potassium can worsen the condition. By understanding the need to decrease potassium-rich foods, the client shows comprehension of the dietary management required for hyperkalemia. Choice A is incorrect because increasing potassium-rich foods would exacerbate hyperkalemia. Choice C is incorrect since increasing sodium-rich foods is unrelated to managing hyperkalemia and could potentially lead to other health issues. Choice D is incorrect as decreasing sodium-rich foods is not the primary focus when managing hyperkalemia.
A client with hypothyroidism is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?
- A. I should increase my intake of iodine-rich foods.
- B. I should decrease my intake of iodine-rich foods.
- C. I should increase my intake of potassium-rich foods.
- D. I should decrease my intake of sodium-rich foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of iodine-rich foods is beneficial for clients with hypothyroidism as iodine is essential for thyroid hormone synthesis. Adequate iodine intake helps to support thyroid function in individuals with hypothyroidism, making choice A the most appropriate response indicating an understanding of the dietary management for this condition. Choices B, C, and D are incorrect because decreasing iodine-rich foods, increasing potassium-rich foods, or decreasing sodium-rich foods are not the recommended dietary modifications for hypothyroidism. In fact, decreasing iodine-rich foods could exacerbate hypothyroidism due to the essential role of iodine in thyroid hormone production.
A client with hyperlipidemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of foods high in saturated fats.
- B. I should decrease my intake of foods high in cholesterol.
- C. I should increase my intake of foods high in trans fats.
- D. I should decrease my intake of foods high in fiber.
Correct Answer: B
Rationale: The correct answer is B. In hyperlipidemia management, decreasing the intake of foods high in cholesterol is crucial to improve lipid levels and reduce the risk of cardiovascular diseases. Choices A and C are incorrect as increasing intake of saturated fats or trans fats can raise cholesterol levels, worsening the condition. Choice D is incorrect because decreasing intake of foods high in fiber is not recommended as fiber-rich foods are beneficial for heart health, which is important in managing hyperlipidemia.
Which of the following statement best describe subjective data?
- A. Measurable by the nurse
- B. Reported by the client
- C. Always accurate
- D. A physical finding
Correct Answer: B
Rationale: Subjective data is reported by the client (B), per assessment e.g., pain level. Not measurable (A), not always accurate (C), not physical (D) client-based. B best defines subjective's source, making it correct.