Nokea
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is most effective in reducing blood pressure?
- A. Increasing dietary potassium intake.
- B. Reducing daily sodium intake.
- C. Drinking one glass of red wine daily.
- D. Taking a daily multivitamin.
Correct Answer: B
Rationale: Reducing sodium intake is highly effective in lowering blood pressure by decreasing fluid retention and vascular resistance.
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The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?
- A. Assessment
- B. Movement
- C. Understanding level
- D. Risks
Correct Answer: D
Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.
The nurse should instruct the client prescribed docusate to monitor for which intended effect of the medication?
- A. Abdominal pain
- B. Decreased heartburn
- C. Decrease in fatty stools
- D. Regular bowel movements
Correct Answer: D
Rationale: Docusate is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, relieve heartburn, or decrease the amount of fat in the stools.
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
- A. External.
- B. Cyanosis.
- C. Dyspnea.
- D. Weight loss.
Correct Answer: C
Rationale: Dyspnea indicates inadequate oxygenation, suggesting the activity level may be too strenuous for the client's cardiac capacity post-myocardial infarction.
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.
A client with a history of chronic kidney disease is prescribed darbepoetin alfa (Aranesp). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Darbepoetin alfa can cause hypertension due to increased red blood cell production, requiring monitoring.