A
The nurse is teaching a client who has mild hypertension about nutritional options. What should the nurse recommend that the client change in the daily diet?
A. Avoid green leafy vegetables.
B. Choose foods with simple sugars.
C. Limit foods high in fiber.
D. Decrease intake of canned foods.
D. Decrease intake of canned foods.
The client with hypertension should select foods low in sodium. Decreasing the intake of canned foods can decrease salt intake. Increasing leafy green vegetables and fiber in a client's diet help maintain blood pressure and weight. Foods containing simple sugars should be exchanged for complex carbohydrates to aid in weight control.
Which information should the nurse provide when teaching a client with diabetes about the role of glucose in the body?
A. It provides energy for cells.
B. It synthesizes proteins.
C. It stimulates osteogenesis.
D. It exacerbates cachexia.
A. It provides energy for cells.
Normal control mechanisms ensure sufficient circulating blood glucose to meet the body's constant energy needs (including basal metabolic energy needs during sleep) because glucose is the body's preferred fuel. Under normal conditions, the body converts glucose to adenosine triphosphate (ATP), which provides the energy needed for the body's metabolic processes.
The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take to remove the transparent adhesive film dressing?
A. Remove the adhesive dressing with water, mineral oil, or petrolatum.
B. Change the adhesive dressing daily and PRN if edge is loose.
C. Use scissors to release the edge and remove the adhesive dressing.
D. Grasp the adhesive dressing edge and peel off in one direction.
A. Remove the adhesive dressing with water, mineral oil, or petrolatum.
The use of adhesives should be minimized as much as possible in pre-term neonates due to fragile skin that tears easily. The nurse should remove the adhesive dressing using small amounts of water, mineral oil, or petrolatum that is applied with a small cotton tipped applicator.
Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?
A. "Protein helps the fetus grow while I am pregnant."
B. "Gestational diabetes is prevented by eating protein."
C. "Anemia is averted by consuming enough protein."
D. "My baby will develop strong teeth after he is born."
A. "Protein helps the fetus grow while I am pregnant."
Adequate protein intake is essential to meet increasing demands of rapid growth of the fetus and maternal changes during pregnancy, such as enlargement of the uterus, mammary glands, and placenta, increase in the maternal blood volume, and formation of amniotic fluid. Protein is essential for anabolism, but its consumption does not prevent gestational diabetes. Iron found in high protein foods, such as meat, helps prevent anemia, but the basic need for protein is the anabolic growth processes of the fetus. Although calcium is needed for fetal bone and teeth development, it is not found in all protein food sources.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
A. Wear support stockings.
B. Reduce salt in her diet.
C. Move about every hour.
D. Avoid constrictive clothing.
C. Move about every hour.
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.
The nurse formulates the nursing diagnosis "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
A. Does not check capillary blood glucose as directed.
B. Occasionally forgets to take daily prescribed medication.
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in health.
D. Eats anything and does not think diet makes a difference in health.
The nursing diagnosis of ineffective health maintenance related to lack of motivation refers to the client's choice not to identify, manage, and/or seek out help to maintain health. This is best exemplified in the client's demonstration and belief about the interaction between diet and health maintenance of Type 2 diabetes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV STAT for a client. On hand is an ampoule labeled, furosemide (Lasix) 20 mg/2mL. How many milliliters should the nurse administer?
A. 1 mL
B. 1.5 mL
C. 1.75 mL
D. 2 mL
B. 1.5 mL
The correct calculation: Dosage on hand/amount on hand = Dosage desired/X amount. 20 mg : 2 mL = 15 mg : X
20X = 30
X = 30/20 = 1 1/2 or 1.5 mL
During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?
A. Discontinue all forms of contraception.
B. Make sure to include adequate folic acid in the diet.
C. Lose weight so more weight is gained during pregnancy.
D. Continue to take any medications that are taken regularly.
B. Make sure to include adequate folic acid in the diet.
A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period reduces the risk of neural tube defects. Recommendations to stop or continue medications during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy is not indicated as a generalization and may place the client at risk for nutritional deficiencies.
Which statement by a client warrants further instruction by the nurse about the changing insulin needs of a diabetic client during pregnancy?
A. "Episodes of hypoglycemia are more likely to occur during the first 3 months."
B. "I will increase my insulin dosage by 5 units each month during the first trimester."
C. "Insulin dosage will likely need to be increased during the second and third trimesters."
D. "Breastfeeding will decrease my insulin needs to lower than my prepregnancy levels."
B. "I will increase my insulin dosage by 5 units each month during the first trimester."
Insulin needs during pregnancy are determined individually according to the client's glucose levels. Insulin needs in the first trimester may actually decrease, so the client's statement about increasing her insulin dose, indicates the need for reteaching
The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the nurse use to determine the client's pain?
A. Use the FACES pain scale.
B. Ask client to rate pain on a scale of 1 to 10.
C. Observe for facial grimacing.
D. Review documentation of recent eating habits.
C. Observe for facial grimacing.
Observing for facial grimacing is the best method for evaluating pain for a client who cannot communicate due to Alzheimer's disease.
What information should the nurse include in a teaching plan about the onset of menopause? (Select all that apply).
A. Smoking.
B. Oophorectomy with hysterectomy.
C. Early menarche.
D. Cardiac disease.
E. Genetic influence.
F. Chemotherapy exposure.
A,B, C, E
Menopausal symptoms are related to the cessation of ovarian function. Factors influencing the onset of menopause include smoking, genetic influences, early menarche, surgical removal, and exposure to chemotherapy agents and radiation. Cardiovascular disease is unrelated.
A client is to receive an IV of Sodium Chloride 0.9% injection (Normal Saline) 250 mL with KCl 10 mEq IV over 4 hours. What rate should the nurse program the client's IV infusion pump?
A. 13 mL/hour.
B. 63 mL/hour.
C. 80 mL/hour.
D. 125 mL/hour.
B. 63 mL/hour
To calculate the infusion rate, the dose of KCl is not used in the calculation. Using the total volume of Normal Saline solution, 250 mL/4 hours = 63 mL/hour.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
A. "Herbs are a cornerstone of good health to include in your treatment."
B. "Touch is also therapeutic in relieving discomfort and anxiety."
C. "Your healthcare provider should direct treatment options for herbal therapy."
D. "It is important that you want to take part in your care."
D. "It is important that you want to take part in your care."
Clients need to be viewed holistically. By acknowledging the emphasis the client made to alternative and complementary therapies, such as herbal therapy, the client is empowered as an integral member of the healthcare team.
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?
A. Have the client empty her bladder.
B. Request the client lie on her left side.
C. Perform Leopold's maneuvers first.
D. Give the client some cold juice to drink.
A. Have the client empty her bladder
Bladder must be empty to accurately measure fundal height
The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process?
A. Encourage the family to give the client permission to die.
B. Revoke the "do not resuscitate" advanced directive.
C. Send the family to an area to seek spiritual comfort.
D. Give the client pain medication during the end of life hours.
A. Encourage the family to give the client permission to die.
Family members often have difficulty letting go of a dying family member. The nurse should encourage the family to give the client permission to die.
A client at 32-weeks' gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved?
A. 4+ reflexes.
B. Urinary output of 50 mL per hour.
C. A decrease in respiratory rate from 24 to 16.
D. A decreased body temperature.
C. A decrease in respiratory rate from 24 to 16.
Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
A 38-year-old gravida 2 para 2 is diagnosed with bacterial vaginosis 9-months postpartum. A prescription is written for metronidazole (Flagyl). Which information is most important for the nurse to obtain from the client before initiating treatment?
A. Sexual history.
B. Use of oral contraceptives.
C. Method of infant feeding.
D. Possibility of pregnancy.
C. Method of infant feeding
Flagyl is contraindicated if the woman is breastfeeding because high concentrations have been found in breast milk fed to infants. If Flagyl must be prescribed, the woman should be instructed to pump and discard the milk during treatment and for 48 to 72 hours after the last dose.
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client?
A. Risk for injury.
B. Impaired comfort.
C. Disturbed body image.
D. Ineffective health maintenance.
B. Impaired comfort.
In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "Impaired comfort."
The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What actions should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
A. Pre-medicate the client with an analgesic.
B. Inform the client of the plan for moving to the chair.
C. Obtain and place a portable commode by the bed.
D. Ask the client to push the IV pole to the chair.
E. Clamp the indwelling catheter.
F. Assess the client's blood pressure.
A, B, D
Pre-medicating the client with an analgesic reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair and encourage the client to participate by pushing the IV pole when walking to the chair. The nurse should assess the client's blood pressure prior to mobilization, which can cause orthostatic hypotension.
A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority?
A. Pain assessment.
B. Respiratory assessment.
C. Cardiovascular assessment.
D. Integumentary assessment.
A. Pain assessment.
Frequent pain assessments are the most important interventions in delivering end-of-life care for a client. The goal of end-of-life treatment is to manage a client's symptoms to provide a pain-free and stress-free environment to improve a client's quality of life.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?
A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue."
B. "We want your baby to be healthy, and this is the only way we can make sure that will happen."
C. "I know you're upset. Would you like to talk about some things you could do while in bed?"
D. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."
A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue."
The healthcare provider prescribed activity restriction and complete bedrest to this client in order to help preserve cardiac reserves.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?
A. Gestational diabetes.
B. Elevated blood pressure.
C. Urinary tract infection.
D. Swelling in lower extremities.
A. Gestational diabetes
The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. Which assessment finding would provide the nurse the earliest indication that the client is experiencing primary side effects of terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth.
C. Tachycardia and a feeling of nervousness.
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness."
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use?
A. Portable syringe pump.
B. Cassette infusion pump.
C. Volumetric controller.
D. Nonvolumetric controller.
B. Cassette infusion pump.
A cassette pump should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as mL/hour. A syringe pump is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric and nonvolumetric controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variations in drop size.
A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first?
A. Initiate a referral for a mental health consultation.
B. Encourage the client to participate in their plan of care.
C. Review the client's medical record for documented religious preference.
D. Contact the hospital chaplain to provide spiritual counseling and guidance.
C. Review the client's medical record for documented religious preference.
The nurse needs to confirm the client's religious preference first before initiating any other action. Individuals who follow the teachings of Buddha believe that "detachment" is the way to obtain relief from suffering. The teachings of Buddha also believe dying is natural process and in reincarnation. When an individual dies, the Buddhist believes the person is transitioning into a new life.