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Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?
- A. Grilled chicken with steamed vegetables
- B. Tofu stir-fry with rice
- C. Pasta with marinara sauce
- D. Baked salmon with quinoa
Correct Answer: C
Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.
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A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?
- A. Limit sodium intake to 2 grams per day.
- B. Choose fresh fruits and vegetables.
- C. Drink at least 8 glasses of water daily.
- D. Avoid processed foods and canned soups.
Correct Answer: D
Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.
A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?
- A. Take the medication with meals to reduce the risk of GI upset.
- B. Report any muscle pain to the healthcare provider promptly.
- C. Avoid alcohol consumption while taking this medication.
- D. Monitor blood sugar levels regularly to prevent hypoglycemia.
Correct Answer: C
Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.
A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?
- A. Nausea and vomiting.
- B. Altered consciousness within the first 24 hours after injury.
- C. Severe headache and blurred vision.
- D. Loss of motor function on the affected side.
Correct Answer: B
Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.
The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?
- A. Administer pre-transfusion medication
- B. Ensure the client has an adequate fluid intake
- C. Monitor the client's vital signs
- D. Verify the blood type with another nurse
Correct Answer: D
Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.
A mother reports that she has been applying triple antibiotic ointment for her son's athlete's foot for two days with no improvement. What should the nurse instruct?
- A. Continue using the ointment and keep the area clean.
- B. Stop using the ointment and encourage the feet to be dried completely.
- C. Apply a different antifungal medication instead.
- D. Reapply the ointment twice a day for a longer period.
Correct Answer: B
Rationale: Antibiotic ointment is ineffective against athlete's foot, which is a fungal infection. The nurse should instruct the mother to stop using the ointment and ensure the feet are dried properly, as moisture exacerbates fungal infections. Applying a different antifungal medication is a valid option, but addressing the moisture issue by drying the feet completely is the immediate priority. Continuing to use the antibiotic ointment or reapplying it for a longer period will not treat the fungal infection effectively.