Nokea
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is MOST appropriate?
- A. Limit exercise to once a week.
- B. Consume a high-sodium diet.
- C. Lose weight if overweight.
- D. Increase alcohol intake.
Correct Answer: C
Rationale: Weight loss reduces blood pressure in hypertensive clients. Options A, B, and D worsen hypertension.
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The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).
- A. Which arterial blood gas result is expected in a client with chronic COPD?
- B. pH 7.40, PaCO2 40 mmHg, PaO2 90 mmHg.
- C. pH 7.32, PaCO2 50 mmHg, PaO2 70 mmHg.
- D. pH 7.45, PaCO2 30 mmHg, PaO2 95 mmHg.
- E. pH 7.30, PaCO2 35 mmHg, PaO2 85 mmHg.
Correct Answer: B
Rationale: Chronic COPD causes CO2 retention, leading to a compensated respiratory acidosis with low pH (7.32), high PaCO2 (50 mmHg), and low PaO2 (70 mmHg) due to impaired gas exchange. Normal or acute values are incorrect.
An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding.
Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client's emotional support?
- A. My husband will be so angry with me if I lose this baby.
- B. I'm afraid I am going to lose my baby.
- C. I can't stay here. I don't have any insurance.
- D. I feel so guilty. I didn't want to get pregnant.
Correct Answer: A
Rationale: Strategy: Think about what the words mean. (1) correct-client's concern about her husband's feelings indicates that he may not be able to support her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
The nurse is caring for a client with a history of heart failure who is receiving torsemide (Demadex) 20 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L
- B. Sodium 140 mEq/L
- C. Creatinine 1.2 mg/dL
- D. Glucose 100 mg/dL
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) is a serious torsemide side effect, risking arrhythmias in heart failure. Options B, C, and D are normal.
An adult is admitted with deep partialthickness and full-thickness burns on both lower legs, the anterior chest, and the anterior and posterior aspects of the right arm. Using the Rule of Nines, calculate the percentage of body burned.
- A. 27%
- B. 36%
- C. 45%
- D. 63%
Correct Answer: B
Rationale: Using the Rule of Nines: both lower legs (18%), anterior chest (9%), right arm anterior and posterior (9%) = 18 + 9 + 9 = 36% total body surface area burned.
The nurse is caring for a client with a history of dementia.
- A. Which intervention is most effective for communicating with a client with dementia?
- B. Speak loudly to ensure understanding.
- C. Use simple, clear sentences.
- D. Ask open-ended questions.
- E. Provide written instructions.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.