A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

"Bake or grill the meat rather than frying it."

“Check your radial pulse twice a day.”

"Read food labels to determine sodium content."

“Weigh yourself every morning and every night."

Answer and Explanation

The Correct Answer is C

A. "Bake or grill the meat rather than frying it."

This statement is more related to reducing fat intake rather than managing sodium levels. While reducing fried foods can be beneficial for overall health, it doesn't directly address the issue of sodium intake, which is crucial in managing hypernatremia.

B. “Check your radial pulse twice a day.”

Checking the radial pulse is a method used to monitor heart rate and rhythm. It is not directly related to managing sodium levels or hypernatremia. Although monitoring vital signs is important in general health care, it is not specific to addressing mild hypernatremia.

C. "Read food labels to determine sodium content."

This statement is the correct choice. Managing sodium intake is a key component in managing hypernatremia. Reading food labels helps patients identify high-sodium foods and make choices that are lower in sodium content, which can be crucial in preventing or managing mild hypernatremia.

D. “Weigh yourself every morning and every night."

While regular weight monitoring can be important for certain health conditions, it is not directly related to managing mild hypernatremia. Weight changes may occur with fluid retention or loss, but monitoring sodium intake and hydration status is more directly relevant to managing hypernatremia.

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Correct Answer is A

Explanation

A. Intact skin with nonblanchable redness, painful, warm, soft localized area over a bony prominence

Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness over a localized area, typically over a bony prominence like the sacrum, heel, or elbow. The skin may feel painful, warm, and soft to the touch. Nonblanchable redness means that when pressure is applied to the area, the redness does not fade or blanch (turn white). This stage indicates that tissue damage has occurred, but the skin is still intact.

B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising: This description is more indicative of a Stage 2 pressure injury, which involves partial-thickness skin loss with an intact or ruptured blister. The wound bed is usually pink or red, and there is no sloughing or bruising.

C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling: This description corresponds to a Stage 3 or Stage 4 pressure injury. Stage 3 involves full-thickness tissue loss with visible subcutaneous fat but no bone, tendon, or muscle exposed. Stage 4 involves extensive tissue loss with exposure of bone, tendon, or muscle. Both stages may include slough (yellow or white tissue) and black eschar (hard, necrotic tissue), along with undermining (tissue destruction under intact skin edges) and tunneling (narrow passageways extending from the wound).

D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling: This description also corresponds to a Stage 3 pressure injury, as it involves full-thickness tissue loss with visible subcutaneous fat. The mention of possible undermining and tunneling further suggests a Stage 3 pressure injury.

A. “All preoperative patients get this medication." B. “The physician prescribed this medication for you." C. "It helps present ulcers from the stress of the surgery." D. “Since you don't have ulcers, I will have to ask."

Correct Answer is C

Explanation

A. “All preoperative patients get this medication.” This statement is too broad and not entirely accurate. While many preoperative patients do receive famotidine (Pepcid), it’s not a standard for all. Medications are prescribed based on individual patient needs and medical history.

B. “The physician prescribed this medication for you.” While this is technically true, it doesn’t provide the patient with an understanding of why the medication is necessary. As a nurse, part of your role is to educate patients about their medications.

C. “It helps prevent ulcers from the stress of the surgery.” This is the correct answer. Famotidine (Pepcid) is given to decrease the amount of acid produced in the stomach, which can help prevent stress ulcers that can occur due to the physical stress of surgery.

D. “Since you don’t have ulcers, I will have to ask.” This statement suggests uncertainty and a lack of knowledge about the medication’s purpose. It’s important for healthcare professionals to understand the medications they administer and be able to explain them to patients.

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A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What would be considered early signs/symptoms of pressure injury (Stage 1)?

Correct Answer is A

Explanation

A nurse is giving a preoperative patient a dose of famotidine ( Pepcid). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?

Correct Answer is C

Explanation

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