An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

Reinforce need for adequate hydration.

Provide typed instructions for healthy diet selection.

Schedule follow-up appointments with specialists.

Demonstrate specific breathing and walking exercises.

Answer and Explanation

The Correct Answer is C

Choice A reason: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.

Choice B reason: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.

Choice C reason: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.

Choice D reason: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer because getting an eye examination with an ophthalmologist annually is an important point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the eyes, leading to vision problems and eye diseases such as diabetic retinopathy, cataracts, and glaucoma. Regular eye check-ups can help detect and treat these conditions early and prevent blindness.

Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.

Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.

Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.

A. Monitor indwelling urinary catheter and measure strict intake and output. B. Keep the bed in the lowest position and initiate seizure and fall precautions. C. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Maintain elevated positioning of the dependent joints on affected side. L. thium [Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L]

Correct Answer is C

Explanation

Choice A reason: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.

Choice B reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.

Choice C reason: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA), which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.

Choice D reason: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.

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An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statementby the client indicates understanding?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse is providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

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