when teaching a client with coronary artery disease about nutrition the nurse should emphasize

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. When teaching a client with coronary artery disease about nutrition, what should the nurse emphasize?

A. Eating three balanced meals a day
B. Adding complex carbohydrates
C. Avoiding very heavy meals
D. Limiting sodium intake to 7 g per day

Correct answer: C

Rationale: The correct answer is to emphasize avoiding very heavy meals. Eating large, heavy meals can divert blood away from the heart for digestion, potentially endangering clients with coronary artery disease. This practice may lead to an increased risk of plaque accumulation in the arteries, potentially obstructing the delivery of blood and oxygen to vital organs. Choices A, B, and D are incorrect. While eating three balanced meals a day, adding complex carbohydrates, and limiting sodium intake are generally good dietary practices, they are not the primary focus when teaching a client with coronary artery disease about nutrition. The emphasis should be on avoiding heavy meals that can strain the cardiovascular system.

2. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

A. Kussmaul respirations
B. Cheyne-Stokes respirations
C. Biot's respirations
D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

3. Which of the following conditions increases a client's risk of aspiration of stomach contents?

A. A client is in restraints
B. A client has a scaphoid abdomen
C. A client is lying prone
D. More than one answer is correct

Correct answer: A

Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.

4. Which of the following is an example of restorative care?

A. A nurse teaches a new mother how to breastfeed her infant
B. A nurse helps a client with developing a bladder-retraining program
C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.

5. Family members of a patient ask repeated questions about the monitors and various readings in the patient's room. What is the most supportive response to their questions?

A. Inform them that you can't take the time to answer all their questions
B. Provide detailed explanations for each device
C. Tell them it's too technical to explain
D. Provide an overview and encourage them to spend their time with the patient

Correct answer: D

Rationale: Addressing the family's questions and providing an overview of information validates their concerns and addresses their requests. Limiting details and encouraging them to focus on the patient helps to avoid anxiety that could be created by focusing on values that should be interpreted in the context of the patient's situation by professionals with experience with such data. It also encourages them to provide what they uniquely have to offer: a comforting presence for their loved one. Choice A is dismissive and does not address the family's needs. Choice B may overwhelm the family with unnecessary technical information. Choice C is unhelpful as it disregards the family's genuine interest and concern. Therefore, choice D is the most appropriate response as it balances providing information while guiding the family to focus on supporting the patient.