Nokea
The nurse is teaching a client with a new diagnosis of heart failure about sodium restriction. Which of the following foods should the client avoid?
- A. Fresh apples.
- B. Canned soups.
- C. Baked chicken.
- D. Brown rice.
Correct Answer: B
Rationale: canned soups are high in sodium, which should be limited in heart failure to prevent fluid retention
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The nurse has orders for dopamine at 20 mcg/kg/min. The bag has 500 mg of dopamine in 500 mL. The client weighs 60 kg. What rate will the nurse set?
Correct Answer: 72 mL/hr
Rationale: Dose: 20 mcg/kg/min × 60 kg = 1200 mcg/min. Concentration: 500 mg/500 mL = 1 mg/mL = 1000 mcg/mL. Rate: 1200 mcg/min ÷ 1000 mcg/mL = 1.2 mL/min × 60 min/hr = 72 mL/hr.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- A. Intrauterine device
- B. Oral contraceptives
- C. Diaphragm
- D. Contraceptive sponge
Correct Answer: C
Rationale: The diaphragm is suitable for diabetic clients as it avoids hormonal effects that could impact glucose control.
The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure was on the right side of the heart?
- A. Jugular vein distention
- B. Dry, nonproductive cough
- C. Orthopnea
- D. Crackles on chest auscultation
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to jugular vein distention, a hallmark sign of impaired right heart function.
If the nurse is providing education to a male client who is HIV positive, which of the following information should the nurse include? Select all that apply.
- A. Need to use condoms for every sexual encounter.
- B. Need to tell sexual or needle-sharing partners about HIV status.
- C. Signs and symptoms indicating increased viral load and infections.
- D. Importance of maintaining a healthy lifestyle.
- E. Availability of support groups.
Correct Answer: A,B,C,D,E
Rationale: HIV education includes condoms (A), disclosing status (B), monitoring symptoms (C), healthy lifestyle (D), and support groups (E) to manage disease and prevent transmission.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 gm/dL
Correct Answer: C
Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.