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Which of the following statements about sodium are true for a client newly diagnosed with hypertension? Select all that apply.
- A. Sodium cannot be completely eliminated from the diet.
- B. There is no sodium in fresh fruits and vegetables.
- C. Canned vegetables should be avoided.
- D. The body needs some sodium as it plays an important role in water balance.
- E. Reduce daily sodium intake to 2,000 mg
Correct Answer: A,C,D
Rationale: Sodium is naturally present in many foods, making complete elimination impossible. B: Incorrect - Fresh fruits and vegetables contain small amounts of sodium naturally. C: Correct - Canned vegetables are high in sodium and should be avoided or rinsed. D: Correct - Sodium is essential for fluid balance and nerve function. E: Incorrect - Guidelines recommend reducing sodium to 1,500 mg/day for hypertension, not 2,000 mg.
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The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the exhibit for additional client information.
- A. bupropion 150 mg XL PO Daily
- B. clonidine 0.1 mg PO Daily
- C. albuterol 2.5 mg via nebulizer Daily
- D. captopril 12.5 mg PO Daily
Correct Answer: D
Rationale: Captopril, an ACE inhibitor, requires clarification if renal function is impaired (e.g., elevated creatinine), as it can worsen kidney injury.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
The nurse is planning care for a client admitted with infective endocarditis (IE). Which assessment finding would indicate that the client is experiencing a complication?
- A. petechial rashes
- B. flank pain
- C. headache
- D. fever
Correct Answer: B
Rationale: Flank pain may indicate renal embolism, a complication of infective endocarditis due to septic emboli.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). It would be correct for the nurse to document this tracing as.
- A. sinus bradycardia.
- B. normal sinus rhythm with first degree block.
- C. atrial flutter.
- D. atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves, as described.
Which action should the nurse prepare to take for a client experiencing a myocardial infarction? Select all that apply.
- A. Start a peripheral vascular access device (VAD)
- B. Obtain a prescription for albuterol via nebulizer
- C. Obtain a prescription for chewable aspirin
- D. Obtain a prescription for nitroglycerin
- E. Obtain an order for a chest radiograph (x-ray)
- F. Establish continuous cardiac monitoring
Correct Answer: A,C,D,F
Rationale: IV access is needed for medications. B: Incorrect - Albuterol is for respiratory issues, not MI. C: Correct - Aspirin reduces clot formation. D: Correct - Nitroglycerin relieves chest pain and reduces preload. E: Incorrect - Chest X-ray is not a priority in acute MI. F: Correct - Cardiac monitoring detects arrhythmias.