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What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?
- A. Avoid foods such as smoked meats and frozen dinners.
- B. Select foods with less than 4g of sodium as indicated on food labels.
- C. Use soy sauce for flavoring foods instead of table salt.
- D. Processed and prepared foods are typically low in sodium.
Correct Answer: A
Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.
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What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?
- A. Mrs. Guevarra makes the assignment to instruct the staff member
- B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
- C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
- D. Mrs. Guevarra must know how to perform the task being delegated
Correct Answer: C
Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.
Which adolescent student lunch, evaluated by the school nurse, is the least nutritious?
- A. Ham sandwich, apple, and milk
- B. Hamburger, fries, and soft drink
- C. Macaroni and cheese, green beans, and peaches
- D. Meatloaf, broccoli, and pear slices
Correct Answer: B
Rationale: The correct answer is B: Hamburger, fries, and soft drink. This meal is considered the least nutritious among the options provided due to its high content of unhealthy fats, processed carbohydrates, and added sugars, which lack essential nutrients. On the other hand, choice A: Ham sandwich, apple, and milk, offers a balanced meal with protein, fiber, vitamins, and calcium. Choice C: Macaroni and cheese, green beans, and peaches, provides a mixture of carbohydrates, vegetables, and fruits. Choice D: Meatloaf, broccoli, and pear slices, includes protein, fiber, and vitamins. Thus, all choices except B provide a more balanced and nutritious meal.
Where should a nurse auscultate the apex beat?
- A. At the fifth intercostal space, along the midclavicular line
- B. At the mid-sternum
- C. 2 inches to the left of the lower end of the sternum
- D. 1 inch to the left of the xiphoid process
Correct Answer: A
Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.
Which of the following is a normal change observed in an elderly individual?
- A. Enhanced sense of taste
- B. Increased appetite
- C. Frequent urination
- D. Lens thinning
Correct Answer: C
Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.
What is the primary food safety concern for a patient undergoing chemotherapy?
- A. Possible food allergy reactions
- B. Possible food-drug interactions
- C. Possible pesticide residue
- D. Potential risk of foodborne illness
Correct Answer: D
Rationale: The correct answer is D: Potential risk of foodborne illness. Patients undergoing chemotherapy have compromised immune systems, making them more susceptible to foodborne illnesses. Chemotherapy can reduce the count of white blood cells, which impairs the body's ability to fight off infections from bacteria or other pathogens that might be present in food. Therefore, the prevention of foodborne illnesses is a critical concern for these patients. Choices A, B, and C, while they represent valid concerns for food safety in general, are not the primary concern for patients undergoing chemotherapy. These patients are at a heightened risk of experiencing severe complications from foodborne illnesses, making it a more significant concern than potential food allergies, food-drug interactions, or pesticide residues.