Nokea
Select the 3 statements the nurse should include in the teaching.
- A. Notify your provider if you experience vomiting or diarrhea.
- B. Limit alcohol intake to no more than one drink per day
- C. You should eat foods that are low in fat.
- D. You can drink beverages that contain caffeine.
- E. You should eat foods highs in protein.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important as vomiting and diarrhea can lead to dehydration. B is crucial for liver health and overall well-being. C is essential for heart health and maintaining a healthy weight. The other choices are incorrect. D can worsen symptoms and interfere with medication. E may not be suitable for certain health conditions and can lead to weight gain. No information is provided for options F and G.
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Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. Bradypnea, or slow breathing, is a critical finding that can indicate respiratory compromise and potentially lead to respiratory failure. It requires immediate attention to prevent further deterioration.
Constipation (A) is important but not as urgent as addressing a respiratory issue. Sedation (B) and euphoria (D) are side effects that may need monitoring but do not pose immediate threats to the patient's health.
In summary, addressing bradypnea is the priority to ensure the patient's respiratory function and prevent a life-threatening situation.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it stenile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (B) can introduce contaminants to the field, holding the bottle in the center (C) does not prevent contamination, and the orientation of the label (D) does not affect sterility.
Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
Which of the following actions should the nurse take? Select all that apply.
- A. Have a second nurse confirm the information on the blood label
- B. Insert a large bore IV catheter
- C. Witness the client signing a consent for transfusion.
- D. Flush the transfusion tubing with dextrose SM in water.
- E. Explain to the client that transfusion reactions are not serious
Correct Answer: A,B
Rationale: The correct actions are A and B. A second nurse confirming the information on the blood label ensures accuracy and prevents errors. Inserting a large bore IV catheter allows for rapid transfusion and prevents complications. Choice C ensures informed consent but is not directly related to the transfusion process. Choice D is incorrect because dextrose cannot be used to flush transfusion tubing. Choice E is incorrect as it provides inaccurate information to the client.