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Why is a low-protein diet recommended for a patient with renal failure?
- A. To prevent fluid overload
- B. To reduce nitrogenous waste
- C. To maintain electrolyte balance
- D. To prevent hyperglycemia
Correct Answer: B
Rationale: The correct answer is B: To reduce nitrogenous waste. In renal failure, the kidneys cannot effectively filter waste products like urea and creatinine, leading to their accumulation in the blood. A low-protein diet reduces the production of these nitrogenous wastes, lessening the burden on the kidneys.
A low-protein diet does not directly prevent fluid overload (A), maintain electrolyte balance (C), or prevent hyperglycemia (D) in renal failure. These functions are typically managed through other dietary modifications and treatments specific to each condition.
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A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What advice should the nurse give regarding insulin administration?
- A. Skip your insulin dose until you can eat.'
- B. Take your insulin as prescribed, but monitor your blood glucose closely.'
- C. Reduce your insulin dose by half.'
- D. Only take your long-acting insulin.'
Correct Answer: B
Rationale: The correct answer is B because skipping insulin can lead to dangerous complications like diabetic ketoacidosis. Taking insulin as prescribed ensures blood glucose control, preventing hyperglycemia. Monitoring blood glucose closely helps adjust doses accordingly. Choice A is incorrect as skipping insulin can be life-threatening. Choice C is incorrect as reducing insulin without proper monitoring can lead to unstable glucose levels. Choice D is incorrect as both long-acting and short-acting insulin are essential for managing type 1 diabetes.
What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct Answer: C
Rationale: The correct answer is C: Avoid exposing the treated area to sunlight. This is important because radiation therapy can make the skin more sensitive to sunlight, leading to increased risk of sunburn and skin damage. Sun exposure can worsen skin reactions and delay healing. Choice A is incorrect because heat sources like heating pads can exacerbate skin irritation. Choice B is incorrect as alcohol-based lotions can further irritate the skin. Choice D is incorrect as hot water and strong soap can be too harsh on the sensitive skin. Overall, protecting the treated area from sunlight is crucial for optimal skin care during radiation therapy.
What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: Rationale:
C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention.
Summary:
A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary.
B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances.
D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.
A patient with tuberculosis is started on rifampin. What advice should the nurse provide?
- A. Limit intake of green leafy vegetables.
- B. Expect orange-red discoloration of body fluids.
- C. Avoid exposure to sunlight.
- D. Take the medication with antacids.
Correct Answer: B
Rationale: The correct answer is B: Expect orange-red discoloration of body fluids. Rifampin is known to cause a harmless side effect of discoloration of body fluids, such as urine, sweat, saliva, and tears, turning them orange-red. This is a common occurrence and should be expected by the patient.
Incorrect choices:
A: Limit intake of green leafy vegetables - This advice is not necessary with rifampin.
C: Avoid exposure to sunlight - There is no direct association between rifampin and sunlight exposure.
D: Take the medication with antacids - Rifampin should not be taken with antacids as they can interfere with its absorption.
In summary, the correct answer is B because it aligns with a known side effect of rifampin, while the other choices are not relevant to the medication.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Tis refers to carcinoma in situ, meaning the cancer is limited to the surface layer of cells in the cervix.
2. N0 indicates no regional lymph node involvement.
3. M0 indicates no distant metastasis.
4. Therefore, the cancer is localized only to the cervix, making answer A correct.
Summary:
B: Incorrect - Does not address the staging information provided in Tis, N0, M0.
C: Incorrect - The staging information is already provided, and further testing may not be necessary at this stage.
D: Incorrect - Staging information does not indicate difficulty in determining the original site of the cancer.