Nokea
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following instructions should be included? Select all that apply.
- A. Reduce sodium intake.
- B. Engage in regular aerobic exercise.
- C. Limit alcohol consumption.
- D. Quit smoking.
- E. Increase saturated fat intake.
Correct Answer: A, B, C, D
Rationale: Reducing sodium, exercising, limiting alcohol, and quitting smoking lower blood pressure. Saturated fats should be avoided.
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A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
A client with a history of stroke is at risk for aspiration. Which intervention is most appropriate?
- A. Offer thin liquids.
- B. Position upright during meals.
- C. Provide large bites of food.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk by aiding swallowing and gravity.
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
The nurse is teaching a client with a new diagnosis of asthma about inhaler use. Which of the following instructions should be included for a metered-dose inhaler?
- A. Shake the inhaler before use.
- B. Hold breath for 10 seconds after inhalation.
- C. Rinse the mouth after each use.
- D. Use a spacer if prescribed.
Correct Answer: A, B, D
Rationale: Shaking the inhaler, holding breath, and using a spacer ensure effective medication delivery.