A nurse is providing teaching for a client who is placed on a low-sodium diet. Which statement made by the client demonstrates an understanding of dietary teaching? "I will:

select organic canned vegetables."

purchase lean deli meats for my sandwiches."

purchase smoked meat products

avoid processed foods."

Answer and Explanation

The Correct Answer is D

D. Processed foods, including canned soups, snacks, and pre-packaged meals, are major sources of dietary sodium. By avoiding processed foods, the client can significantly reduce their sodium intake and better adhere to a low-sodium diet.

A. While organic vegetables may be a healthy choice for other reasons (such as reducing pesticide exposure), canned vegetables, whether organic or not, often contain added sodium for preservation. Therefore, selecting canned vegetables, even if organic, may not align with the goal of reducing sodium intake.

B. This statement suggests an understanding of choosing lower-sodium options for sandwiches. Lean deli meats, such as turkey or chicken breast, typically contain less sodium compared to processed or cured meats like salami or bologna. Opting for lean deli meats supports the client's effort to reduce sodium intake as part of a low-sodium diet.

C. This statement indicates a misunderstanding of a low-sodium diet. Smoked meats, such as smoked ham or bacon, are often high in sodium due to the curing and smoking process. Including smoked meat products in the diet would likely increase sodium intake, which contradicts the goal of reducing sodium.

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Correct Answer is B

Explanation

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

A. The ulcer has thick dark eschar over the top B. Exposed bone/tendon is visible C. There is partial-thickness loss of dermis D. The wound extends into the subcutaneous tissue.

Correct Answer is B

Explanation

B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.

A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.

C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.

D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.

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A nurse is providing teaching for a client who is placed on a low-sodium diet. Which statement made by the client demonstrates an understanding of dietary teaching? "I will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Correct Answer is B

Explanation

The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

Correct Answer is B

Explanation

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