A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

"I will eat turkey sausage for breakfast."

"I will put ketchup on my hot dogs."

"I will use frozen vegetables rather than canned."

"I like to use store-bought spaghetti sauce."

Answer and Explanation

The Correct Answer is C

A. Eating turkey sausage for breakfast is incorrect. Processed meats, including turkey sausage, are high in sodium and should be avoided in a low-sodium diet. Even "healthier" alternatives can contain significant amounts of added salt.

B. Putting ketchup on hot dogs is incorrect. Ketchup and hot dogs are both high in sodium, making them poor choices for a client managing hypertension.

C. Using frozen vegetables rather than canned is correct. Canned vegetables often contain added sodium for preservation, while frozen vegetables typically have little to no added salt, making them a healthier option.

D. Using store-bought spaghetti sauce is incorrect. Many commercial pasta sauces contain high levels of sodium, which can contribute to increased blood pressure. A low-sodium alternative, such as homemade sauce with fresh ingredients, would be a better choice.

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Correct Answer is B

Explanation

A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.

B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.

C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.

D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.

A. Inspect the incision of a client who is postoperative following a leg amputation. B. Evaluate the need to suction the airway of a client who has a new tracheostomy. C. Complete postmortem care for a client who has died. D. Feed a client who has difficulty swallowing liquids following a stroke.

Correct Answer is C

Explanation

A. Inspect the incision of a client who is postoperative following a leg amputation is incorrect. Inspecting an incision requires clinical assessment to identify signs of infection, dehiscence, or other complications, which should be performed by a licensed nurse.

B. Evaluate the need to suction the airway of a client who has a new tracheostomy is incorrect. Suctioning the airway of a client with a tracheostomy is a skilled task that requires assessment of the airway and airway management, which should be performed by a nurse.

C. Complete postmortem care for a client who has died is correct. Postmortem care, such as cleaning and preparing the body, is a task that can be delegated to an AP. The AP should not be involved in clinical assessments but can perform routine care under supervision.

D. Feed a client who has difficulty swallowing liquids following a stroke is incorrect. Feeding a client with swallowing difficulties requires careful monitoring and risk assessment for aspiration, which is outside the scope of tasks that can be delegated to an AP without proper training.

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A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

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