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 A

Explanation

Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.

Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

A. Check and document the client's vital signs B. Ensure that the client's IV site uses a 22-gauge needle C. Verify that the blood type and Rh of the packed RBCs are checked by two nurses D. Obtain a bag of lactated Ringer's IV solution E. Provide the RN with tubing that has a filter

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

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

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

Explanation

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