Nokea
When reinforcing diet teaching for a client diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply
- A. Orange juice, oranges, bananas
- B. All are applicable
- C. Collard greens, kale, turnips
- D. Soybeans, lima beans, spinach
Correct Answer: B
Rationale: The correct answer is B: All are applicable. Foods rich in potassium, such as orange juice, oranges, bananas, collard greens, kale, soybeans, lima beans, and spinach, are essential for managing hypokalemia. These options provide a significant source of potassium, which helps in maintaining normal heart and muscle function. Choice A is incorrect because it does not include all the appropriate potassium-rich foods. Choice C is incorrect as it only mentions vegetables rich in potassium, missing out on other essential sources like fruits and beans. Choice D is incorrect as it lacks key potassium-rich foods like oranges and bananas.
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A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse's priority action?
- A. Administer pain medication.
- B. Lay the client flat and notify the healthcare provider.
- C. Encourage the client to drink more fluids.
- D. Assess the client's surgical site for drainage.
Correct Answer: B
Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.
A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?
- A. Encourage the client to drink fluids.
- B. Assist the client back to bed and monitor vital signs.
- C. Administer a prescribed antiemetic.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The nurse's priority action should be to assist the client back to bed and monitor vital signs. The client's symptoms of feeling weak and lightheaded could indicate potential issues like hypotension or dehydration, which need to be assessed promptly. Encouraging fluids (Choice A) could be beneficial but is not the immediate priority. Administering an antiemetic (Choice C) may not address the underlying cause of the client's symptoms. Notifying the healthcare provider (Choice D) can be done after the client has been stabilized and assessed.
An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the nurse document as evidence that the amount of insulin is inadequate?
- A. States that her feet are constantly cold and numb
- B. A wound on the ankle that starts to drain and becomes painful
- C. Consecutive evening serum glucose greater than 260 mg/dL
- D. Reports nausea in the morning but still able to eat breakfast
Correct Answer: C
Rationale: The correct answer is C. Consistently high evening glucose levels indicate that the current insulin dosage is inadequate to maintain proper glucose control. Choice A is incorrect because cold and numb feet are more indicative of peripheral vascular disease rather than inadequate insulin dosage. Choice B describes a wound that may be related to poor circulation or neuropathy but not necessarily inadequate insulin dosage. Choice D suggests gastrointestinal issues that are not directly related to insulin dosage adequacy.
After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?
- A. Avoid lifting heavy objects for at least a week.
- B. Follow a low-fat diet.
- C. Monitor the incision sites for signs of infection.
- D. Resume normal activities as tolerated.
Correct Answer: C
Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.
A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement?
- A. Teach the client to use a straw when taking the medication to reduce further tooth staining
- B. Advise the client to withhold further doses until consulting with the healthcare provider
- C. Reassure the client that this change indicates the medication is having the desired effect
- D. Determine if the client is also experiencing mouth or gum pain and difficulty swallowing
Correct Answer: A
Rationale: The correct action for the PN to implement is to teach the client to use a straw when taking the medication to reduce further tooth staining. Using a straw minimizes contact between the iron preparation and the teeth, helping prevent additional staining. Choice B is incorrect because withholding doses without consulting the healthcare provider could be detrimental to the client's health. Choice C is incorrect because darkening of tooth color is not an expected effect of liquid iron preparation and should not be reassured as a desired effect. Choice D is incorrect as it does not directly address the client's concern about tooth staining.