Nokea
The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
- A. I should increase my intake of processed foods.'
- B. I will limit my sodium intake to 2,300 mg per day.'
- C. I can drink coffee as much as I want.'
- D. I should avoid fruits like bananas.'
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
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A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?
- A. Institute droplet precautions.
- B. Obtain the child's vital signs.
- C. Ask the parent about medication allergies.
- D. Inquire about the health of siblings at home.
Correct Answer: A
Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Respiratory distress.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
- A. Increased alertness.
- B. Circulatory collapse.
- C. Hypertension.
- D. Diuresis.
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?
- A. Pinch the nostrils for 5 minutes and then recheck for bleeding.
- B. Maintain the child in a sitting position with the head tilted backward.
- C. Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm.
- D. Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.
Correct Answer: D
Rationale: The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the parent should be instructed that this pinch should be timed by a clock, not estimated. The parent should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.