A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

"I may thicken gravies with cornstarch as I cook."

"Fresh fruits make a good snack option."

"I may eat 2 cans of soup a day."

"I will replace table salt with dried herbs."

Answer and Explanation

The Correct Answer is C

A. Thicken gravies with cornstarch is acceptable as it does not add significant sodium and can be a healthier alternative to flour or other thickening agents.

B. Fresh fruits are indeed a healthy snack option and are encouraged in a heart-healthy diet due to their low sodium and high fiber content.

C. Eating 2 cans of soup a day is concerning because many canned soups are high in sodium, which can exacerbate hypertension. This statement indicates a need for further teaching about sodium intake.

D. Replacing table salt with dried herbs is a positive change that promotes flavor without adding sodium, aligning with heart-healthy dietary recommendations.

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Correct Answer is A

Explanation

A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.

B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.

C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.

D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.

A. Inject the medication 12.7 cm (5 in) below the client's acromion process B. Use a 21-gauge needle for the injection C. Inject the medication at a 90-degree angle D. Inject a volume of less than 2 mL

Correct Answer is D

Explanation

A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.

B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.

C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.

D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.

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A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select All that Apply)

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

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A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first?

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Which of the following rooms should the nurse assign to the client?