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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3.

Exhibits

Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.

"I will restrict my fluid intake to less than 1 L per day."

"It is important to check my blood pressure at different times of the day."

“I understand that I need to restrict potassium in my diet."

“I will check my weight first thing in the morning”

“I will notify my provider if suddenly notice weight gain."

“I only need to check my weight weekly.”

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:

A. "I will restrict my fluid intake to less than 1 L per day." Fluid restriction to less than 1L/day is excessive and unnecessary unless the client has severe fluid retention. The client should follow specific instructions from their healthcare provider regarding fluid intake.

B. "It is important to check my blood pressure at different times of the day." This shows understanding of blood pressure fluctuations. Regular monitoring, especially in those with kidney dysfunction, is important to detect abnormal increases.

C. "I understand that I need to restrict potassium in my diet." Impaired renal function can lead to impaired potassium excretion causing hyperkalemia. Potassium restriction helps prevent cardiac complications from elevated potassium levels.

D. "I will check my weight first thing in the morning." Weighing in the morning gives a consistent baseline to track sudden weight changes, which can indicate fluid retention or worsening kidney function.

E. "I will notify my provider if I suddenly notice weight gain." Rapid weight gain can indicate fluid retention or worsening kidney function. The client should inform their provider if this occurs to prevent complications.

F. "I only need to check my weight weekly." Daily weight monitoring is more appropriate for clients with kidney or heart conditions to detect sudden fluid retention. Weekly checks may miss early signs of fluid retention.

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Correct Answer is D

Explanation

Rationale:

A. Obtain the client's vital signs: While vital signs are important after a seizure, they are not the priority during the event. The first action should focus on protecting the client from injury and ensuring their airway remains open.

B. Notify the rapid response team: Notifying the rapid response team is not the first step. The nurse should prioritize ensuring the client’s safety during the seizure, including turning them on their side to prevent aspiration or injury.

C. Perform a neurologic check: A neurologic check is important after the seizure has ended to assess for changes in mental status or neurological function. However, during the seizure, the immediate priority is to ensure the client’s safety and airway.

D. Turn the client on their side: This priority action during a tonic-clonic seizure helps maintain the airway, prevents aspiration, and allows any secretions to drain from the mouth. Ensuring safety during the seizure is crucial before performing other assessments.

A. Limit engaging in sport activities that can cause bruising. B. Limit socializing in large crowds. C. Decrease intake of fresh fruits or vegetables. D. Decrease time spent outdoors.

Correct Answer is B

Explanation

Rationale:

A. Limit engaging in sport activities that can cause bruising: While it's important to avoid activities that increase the risk of injury, this is not a specific related to radiation therapy. The nurse should focus on such as avoiding infection or exposure to certain environments.

B. Limit socializing in large crowds: This is an important for clients undergoing radiation therapy, especially if their immune system is compromised. Socializing in large crowds increases the risk of exposure to infections..

C. Decrease intake of fresh fruits or vegetables: While radiation therapy can affect the immune system, it doesn't typically cause the level of systemic neutropenia that would warrant this strict dietary restriction unless combined with other treatments.

D. Decrease time spent outdoors: Decreasing time spent outdoors is not a standard recommendation for clients undergoing radiation therapy unless they are directly exposed to the sun. Clients should protect their skin from sun exposure but should not avoid outdoor activities altogether.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3. Exhibits Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3.

Exhibits

Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.