Question 5041)
A low-sodium, low-cholesterol, weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
A. Baked skinless chicken and mashed potatoes
B. Stir-fried Chinese vegetables and rice
C. Tuna fish salad with celery sticks
D. Grilled lean steak with carrots
Answer: A
Explanation: Chicken is lower in sodium than beef or seafood. Baking adds no sodium to the chicken. Barbecuing adds sodium and fat, and frying adds fat and usually sodium. Mashed potatoes contain little sodium. Chinese food is usually high in sodium. Tuna fish and celery are high in sodium. Steak and carrots are high in sodium.
Question 5042)
An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would most likely be present?
A. Distended neck veins
B. Dyspnea
C. Hepatomegaly
D. Pitting edema
Answer: B
Explanation: Dyspnea occurs with left-sided heart failure. Distended neck veins, hepatomegaly, and pitting edema are signs of right-sided heart failure.
Question 5043)
Digoxin (Lanoxin) and furosemide (Lasix) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
A. Potassium
B. Calcium
C. Aspirin
D. Coumadin
Answer: A
Explanation: Lasix is a potassium-depleting diuretic. Digoxin toxicity occurs more quickly in the presence of a low serum potassium. Potassium supplements are usually ordered when the client is on a potassiumdepleting diuretic. There is no indication for supplemental calcium. Aspirin and Coumadin are anticoagulants and are not indicated because the client is taking Lasix and digoxin.
Question 5044)
When the nurse is about to administer digoxin to a client, the client says, “I think I need to see the eye doctor. Things seem to look kind of green today.” The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
A. Administer the medication and record the findings on his chart
B. Withhold the digoxin and report to the charge nurse
C. Request an appointment with the ophthalmologist
D. Reassure the client that he is having a normal reaction to his medication
Answer: B
Explanation: Disturbance in green and yellow vision is a sign of digoxin toxicity. A pulse of 60 is borderline for digoxin toxicity. When there is any possibility of digoxin toxicity, withhold the medication and report to the charge nurse. Once a person takes digoxin, it stays in the system for nearly a week. The LPN will of course record the findings, but withholding the medication is essential. The client needs to have serum digoxin levels done and does not need to be seen by an ophthalmologist. Visual disturbances are a sign of digoxin toxicity, but these are not normal.
Question 5045)
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to do which of the following?
A. Increase activity tolerance
B. Increase activity tolerance
C. Protect from injury
D. Help build a positive body image
Answer: C
Explanation: Because the client has such poor blood supply to his legs, the nurse must be very careful to protect him from injury. Increasing activity tolerance might be desirable but is certainly not the primary nursing goal. Note that the question does not indicate that he has poor exercise tolerance. There are no data in the question to indicate that the client is anxious. He may need help in building a positive body image because his legs are disfigured, but this is certainly not a high priority
Question 5046)
An adult client who has peripheral vascular disease of the lower extremities was observed smoking in the waiting area. What is the most appropriate response for the nurse to make regarding the client’s smoking?
A. “Smoking is not allowed for patients with blood diseases.”
B. “Smoking causes the blood vessels in your legs to constrict and reduces the blood supply.”
C. “Smoking increases your blood pressure and strains your heart.”
D. “Smoking causes your body to be under greater stress.”
Answer: B
Explanation: This is an accurate answer that relates his behavior to his illness. All of the other statements are true about smoking but do not relate to his current health problem.
Question 5047)
An Adult client with peripheral Vascular Disease tells the nurse he is afraid his left leg is not improving and may need to be amputated. How should the nurse respond?
A. “You and your wife should discuss your feelings before surgery.”
B. “You sound concerned about your leg and possible surgery.”
C. “It is better to have an amputation when the ulcers are not improving.”
D. “You don’t need to be afraid of surgery.”
Answer: B
Explanation: This response opens communication and allows him to talk about his feelings. The other answers do not allow him to discuss his feelings with the nurse now.
Question 5048)
An adult is diagnosed with hypertension. He is prescribed chlorothiazide (Diuril) 500 mg PO. What nursing instruction is essential for him?
A. Drink at least two quarts of liquid daily
B. Avoid hard cheeses.
C. Drink orange juice or eat a banana daily.
D. Do not take aspirin
Answer: C
Explanation: Chlorothiazide (Diuril) is a potassium-depleting diuretic. Orange juice and bananas are good sources of potassium. It is not necessary to increase fluids to two quarts when the client is taking a diuretic. Hard cheeses should be avoided when the client is taking monoamine oxidase inhibitors (MAOIs). MAOIs are antidepressants. People who take Coumadin should not take aspirin.
Question 5049)
A low-sodium diet has been ordered for an adult client. The nurse knows that the client understands his low-sodium diet when the client selects which menu?
A. Tossed salad, carrot sticks, and steak
B. Baked chicken, mashed potatoes, and green beans
C. Hot dog, roll, and coleslaw
D. Chicken noodle soup, applesauce, and cottage cheese
Answer: B
Explanation: Chicken is low in sodium, as are mashed potatoes and green beans. Carrot sticks, steak, hot dogs, soup, and cottage cheese are all high in sodium
Question 5050)
A female client is admitted to the hospital with obesity and deep vein thrombophlebitis (DVT) of the right leg. She weighs 275 pounds. Which of the following factors is least related to her diagnosis?
A. She has been taking oral estrogens for the last three years.
B. She smokes two packs of cigarettes daily.
C. Her right femur was fractured recently.
D. She is 30 years old. Answer: D Explanation: Age is least related to DVT. Oral estrogens, smoking, and a broken leg are all risk factors for DVT.
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