Nokea
When caring for a client with hepatic encephalopathy, why is a low-protein diet recommended by the nurse?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Increased ammonia levels
- D. Electrolyte imbalance
Correct Answer: C
Rationale: The correct answer is C: Increased ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia into urea, leading to increased ammonia levels in the blood. A low-protein diet helps reduce ammonia production in the gut, thereby decreasing ammonia levels in the blood and improving symptoms. Hyperglycemia (A) and hypoglycemia (B) are not directly related to the rationale for a low-protein diet in hepatic encephalopathy. Electrolyte imbalance (D) is not specifically addressed by a low-protein diet in this context.
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A patient with heart failure is prescribed digoxin. What is the most important instruction the nurse should provide?
- A. Take an extra dose if you miss one.
- B. Avoid high-potassium foods.
- C. Report any visual disturbances.
- D. Stop taking the medication if your pulse is normal.
Correct Answer: C
Rationale: The correct answer is C: Report any visual disturbances. This is important because digoxin can cause visual disturbances, such as blurred or yellow-tinted vision, which may indicate toxicity. By reporting these symptoms promptly, the nurse can prevent serious complications.
A: Taking an extra dose if a dose is missed can lead to overdose and toxicity.
B: Avoiding high-potassium foods is important for patients taking potassium-sparing diuretics, not digoxin.
D: Stopping the medication if the pulse is normal is incorrect as it should be taken as prescribed for heart failure management.
A patient with asthma is prescribed a corticosteroid inhaler. What is the most important instruction to give to the patient?
- A. Use the inhaler only during asthma attacks.
- B. Rinse the mouth after using the inhaler.
- C. Take a double dose if symptoms worsen.
- D. Avoid using a spacer with the inhaler.
Correct Answer: B
Rationale: The correct answer is B: Rinse the mouth after using the inhaler. This instruction is crucial because corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps prevent this side effect.
A: Using the inhaler only during asthma attacks is incorrect as corticosteroid inhalers are typically used regularly to manage asthma symptoms.
C: Taking a double dose if symptoms worsen is dangerous and can lead to overdose. Patients should follow the prescribed dosage.
D: Avoiding using a spacer with the inhaler is not a universal instruction. Spacers can actually improve the effectiveness of the medication delivery.
When providing dietary instructions to a client with cirrhosis, which dietary restriction is important for the nurse to emphasize?
- A. Low-protein diet
- B. Low-sodium diet
- C. High-fiber diet
- D. High-calcium diet
Correct Answer: B
Rationale: Rationale: Correct answer is B (Low-sodium diet) for cirrhosis because sodium can worsen fluid retention and increase ascites. A (Low-protein diet) is not necessary unless hepatic encephalopathy is present. C (High-fiber diet) can help with constipation but not a primary concern. D (High-calcium diet) is not a priority for cirrhosis management.
A patient with hyperthyroidism is to receive radioactive iodine therapy. What information should the nurse include in the patient teaching plan?
- A. Avoid close contact with pregnant women for one week.
- B. Take iodine supplement daily.
- C. Restrict fluid intake to 1 liter per day.
- D. Use disposable utensils for all meals.
Correct Answer: A
Rationale: The correct answer is A. The rationale is that radioactive iodine therapy can harm a developing fetus, so patients should avoid close contact with pregnant women for one week. Choice B is incorrect as iodine supplements can interfere with the therapy. Choice C is incorrect as fluid intake should not be restricted unless specifically advised by the healthcare provider. Choice D is incorrect as there is no need to use disposable utensils for all meals.
A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?
- A. Administer regular insulin intravenously.
- B. Give oral hypoglycemic agents.
- C. Administer sodium bicarbonate.
- D. Provide a high-calorie diet.
Correct Answer: A
Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.