A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

"I will eat turkey sausage for breakfast."

"I will put ketchup on my hot dogs."

"I will use frozen vegetables rather than canned."

"I like to use store-bought spaghetti sauce."

Answer and Explanation

The Correct Answer is C

A. Eating turkey sausage for breakfast is incorrect. Processed meats, including turkey sausage, are high in sodium and should be avoided in a low-sodium diet. Even "healthier" alternatives can contain significant amounts of added salt.

B. Putting ketchup on hot dogs is incorrect. Ketchup and hot dogs are both high in sodium, making them poor choices for a client managing hypertension.

C. Using frozen vegetables rather than canned is correct. Canned vegetables often contain added sodium for preservation, while frozen vegetables typically have little to no added salt, making them a healthier option.

D. Using store-bought spaghetti sauce is incorrect. Many commercial pasta sauces contain high levels of sodium, which can contribute to increased blood pressure. A low-sodium alternative, such as homemade sauce with fresh ingredients, would be a better choice.

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Correct Answer is B

Explanation

A. Carrying the baby to the nursery is incorrect. Most facilities require that newborns be transported in a bassinet, not carried, to reduce the risk of accidental drops or abductions.

B. Having an identification band that matches the baby’s band is correct. Hospital security protocols require that the mother and baby wear matching identification bands to ensure the right baby is with the right parent and prevent infant abduction or misidentification.

C. Removing the security band to give to a family member is incorrect. The security band must remain on the mother at all times to verify identity when interacting with the baby. Removing it can compromise security.

D. Taking the baby to the lobby to visit family is incorrect. Many hospitals have strict policies requiring newborns to remain in designated areas for security and infection control reasons. Visitors should come to the mother’s room instead.

A. Tell the APs to stop the conversation. B. Document the event in the client's progress notes. C. Inform the client of the APs' actions. D. Submit an incident report to the risk manager.

Correct Answer is A

Explanation

A. Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.

B. Documenting the event in the client's progress notes is incorrect. Client progress notes should contain only information relevant to client care. Documenting an overheard conversation about a privacy violation does not belong in the medical record.

C. Informing the client of the APs' actions is incorrect. While privacy is essential, informing the client may cause unnecessary distress. The nurse should focus on correcting the behavior of the APs rather than alarming the client.

D. Submitting an incident report to the risk manager is incorrect. While some breaches of confidentiality require reporting, the first step is to address the issue directly with the APs. If the behavior continues or is severe, reporting to a supervisor may be necessary.

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A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

Nursing Test Bank

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