Nokea
The nurse is teaching a client with hypertension about dietary modifications. Which of the following foods should the nurse recommend the client avoid?
- A. Baked chicken breast.
- B. Canned vegetable soup.
- C. Fresh apples.
- D. Whole-grain bread.
Correct Answer: B
Rationale: Canned vegetable soup is high in sodium, which can exacerbate hypertension. Options A, C, and D are suitable: baked chicken is low-sodium, apples are heart-healthy, and whole-grain bread supports cardiovascular health.
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The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
- A. White blood cell count of 12,000/mm^3.
- B. Temperature of 100.4°F (38°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
A client after a bronchoscopy.
The nurse would be MOST concerned if which of the following was observed?
- A. Depressed gag reflex.
- B. Sputum streaked with blood.
- C. Tachypnea.
- D. Complaints of a sore throat.
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
The nurse is caring for a client with a history of peripheral artery disease.
- A. Which symptom is expected in a client with peripheral artery disease?
- B. Warm, red skin on the legs.
- C. Intermittent claudication.
- D. Swelling in the ankles.
- E. Numbness in the arms.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.
A client admitted with acute hypoparathyroidism.
It is MOST important for the nurse to have which of the following items available?
- A. Tracheostomy set.
- B. Cardiac monitor.
- C. IV monitor.
- D. Heating pad.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tracheostomy set is the most important for the client's safety due to risk for laryngospasm (2) nice to have, but not the most important (3) nice to have, but not the most important (4) unnecessary