Nokea
The nurse is teaching a client with hypertension about dietary modifications. Which of the following statements by the client would require follow-up?
- A. I'm glad I can still eat beef and pork daily.
- B. I will need to get used to eating fruits and vegetables.
- C. I should avoid eating canned foods.
- D. I already told my spouse to buy me some yogurt when I get home.
Correct Answer: A
Rationale: Daily consumption of red meats like beef and pork is not recommended for hypertension due to high sodium and fat content.
You may also like to solve these questions
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses’ Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data.
Drag a word from the choices below to complete the sentence.
Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
- A. first
- B. second
- C. third
- D. fourth
- E. latent
- F. active
- G. transition
Correct Answer: A, F
Rationale: Cervical dilation of 6 cm with 100% effacement and frequent contractions indicate the first stage of labor, active phase.
The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety?
- A. Assign the client to a private room.
- B. Orient the client to their room.
- C. Request for a sitter to be assigned.
- D. Instruct the UAP to check on the client frequently.
Correct Answer: B
Rationale: Orienting a legally blind client to their room reduces anxiety by promoting safety and familiarity.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 2 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The nurse considers if the client may have an infection caused by a tick. Click to specify if the features are consistent with the disease process of Rocky Mountain spotted fever (RMSF) or Lyme Disease.
- A. Fever
- B. Petechial rash that becomes diffuse
- C. Erythema migrans (bullseye rash)
- D. Myalgia
- E. Causative agent Rickettsia rickettsii
- F. Causative agent Borrelia burgdorferi
Correct Answer: C (Lyme Disease), F (Lyme Disease)
Rationale: The bullseye rash and Borrelia burgdorferi are specific to Lyme disease. Fever and myalgia can occur in both RMSF and Lyme disease, but the petechial rash and Rickettsia rickettsii are specific to RMSF.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)
Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.