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1. A client with chronic kidney disease needs dietary restrictions. What restriction is necessary?
- A. Increase protein intake
- B. Limit potassium-rich foods
- C. Increase fluid intake to prevent dehydration
- D. Increase phosphorus intake
Correct answer: B
Rationale: The correct answer is to limit potassium-rich foods for clients with chronic kidney disease. Excessive potassium can be harmful to individuals with compromised kidney function, leading to complications. This restriction helps in managing the condition and preventing further health issues. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can burden the kidneys. Choice D is incorrect as increasing phosphorus intake can be harmful for individuals with kidney disease.
2. A nurse is preparing to administer a blood transfusion. What is the first action?
- A. Administer the blood through an IV push
- B. Verify the client's blood type before starting the transfusion
- C. Warm the blood to body temperature before administration
- D. Ensure the client eats before starting the transfusion
Correct answer: B
Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.
3. What is an early sign indicating the need for suctioning a client's tracheostomy?
- A. Irritability
- B. Hypotension
- C. Flushing
- D. Bradycardia
Correct answer: A
Rationale: Irritability is a crucial early sign that a client with a tracheostomy may require suctioning. Irritability could indicate a lack of oxygenation due to the airway blockage, prompting the need for suctioning to clear the airway. Hypotension, flushing, and bradycardia are not typically direct indicators for suctioning a tracheostomy. Hypotension may suggest hemodynamic instability, flushing could be related to autonomic responses, and bradycardia might indicate a cardiac issue rather than the need for suctioning.
4. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?
- A. Use pursed-lip breathing during physical activity
- B. Breathe deeply and quickly during exercise
- C. Avoid using the incentive spirometer
- D. Avoid physical activity to conserve energy
Correct answer: A
Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.
5. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?
- A. Ensure the client is fasting before the test
- B. Provide a warm blanket for the client
- C. Apply cold compresses to the client's chest
- D. Instruct the client to remain still
Correct answer: D
Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.
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