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. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

A. Apply the transdermal patch to either of the client's forearms. B. Remove the old transdermal patch before applying a new one. C. Apply the patch to a clean, hairless area of the client's skin. D. Use sterile gloves to apply and remove transdermal patches. E. Dispose of old transdermal patches in a childproof container.

Correct Answer is ["B","C","E"]

Explanation

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

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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

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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