A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?

Chicken breast and corn on the cob

Shrimp and rice

Cheese omelet and turkey bacon

Liver and onions

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct meal selection, because chicken breast and corn on the cob are low in cholesterol and saturated fat, which can help lower the risk of heart disease.

Choice B reason: This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.

Choice C reason: This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.

Choice D reason: This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.

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Correct Answer is D

Explanation

Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.

Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.

Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.

Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.

A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

Correct Answer is B

Explanation

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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