Nokea
Which discharge instruction should the nurse discuss with the client to prevent recurrent episodes of cellulitis?
- A. Soak your feet daily in Epsom salts for 20 minutes.
- B. Wear thick white socks when working in the yard.
- C. Use a mosquito repellent when going outside.
- D. Inspect the feet between the toes for cracks in the skin.
Correct Answer: D
Rationale: Inspecting feet for cracks (D) prevents skin breakdown, a cellulitis entry point in diabetes. Epsom salts (A) are not standard, socks (B) are less specific, and repellent (C) prevents bites but not cracks.
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The nurse knows the client understands the teaching concerning a low-fat, low-cholesterol diet when the client selects which meal?
- A. Fried fish, garlic mashed potatoes, and iced tea.
- B. Ham and cheese on white bread and whole milk.
- C. Baked chicken, baked potato, and skim milk.
- D. A hamburger, French fries, and carbonated beverage.
Correct Answer: C
Rationale: Baked chicken, baked potato, and skim milk (C) are low-fat/low-cholesterol. Fried fish (A), ham/cheese/milk (B), and hamburger/fries (D) are high-fat.
The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.
Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease?
- A. The client has 2+ pedal pulses.
- B. The client is able to move the toes.
- C. The client has numbness and tingling.
- D. The client’s feet are red when standing.
Correct Answer: C
Rationale: Numbness and tingling (C) suggest worsening ischemia or nerve compression, requiring immediate intervention. 2+ pulses (A) and toe movement (B) are normal, and red feet (D) may indicate dependent rubor, less urgent.
The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement?
- A. Praise the client for having a normal cholesterol level.
- B. Explain that the client needs to lower the cholesterol level.
- C. Discuss dietary changes that could help increase the level.
- D. Allow the client to ventilate feelings about the blood test result.
Correct Answer: B
Rationale: Cholesterol 240 mg/dL (B) is high (>200 is abnormal), requiring education to lower it. Praising (A) is incorrect, increasing (C) is harmful, and venting (D) is secondary.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).