Nokea
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
- A. Grape juice
- B. Milk carton
- C. Mixed green salad
- D. Fried chicken breast
Correct Answer: B
Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.
You may also like to solve these questions
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct Answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
- A. Skin turgor
- B. Heart sounds
- C. Mental status
- D. Capillary refill
Correct Answer: C
Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the healthcare provider immediately that the patient is on which medication?
- A. Oral digoxin (Lanoxin) 0.25 mg daily
- B. Ibuprofen (Motrin) 400 mg every 6 hours
- C. Metoprolol (Lopressor) 12.5 mg orally daily
- D. Lantus insulin 24 U subcutaneously every evening
Correct Answer: A
Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias. Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin. Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Tie the knot with a double turn or square knot
- B. Ensure that the restraints are snug against the client's wrists
- C. Ensure that the knot can be quickly released
- D. Move the ties so the restraints are secured to the side rails
Correct Answer: C
Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.
After receiving change-of-shift report, which patient should the nurse assess first?
- A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
- B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
- C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
- D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
Correct Answer: C
Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.