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1. When should a healthcare provider suction a client's tracheostomy?
- A. When the client is hypotensive
- B. When the client is irritable
- C. When the client is flushed
- D. When the client is bradycardic
Correct answer: B
Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.
2. Which nursing intervention is best for a client with constipation?
- A. Encourage the client to remain in bed to avoid straining
- B. Administer a stool softener as prescribed
- C. Increase fiber intake through dietary changes
- D. Encourage regular exercise to promote bowel movement
Correct answer: C
Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.
3. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
- A. You should not gain more than 10 lbs
- B. Your weight gain should be the same as for someone without diabetes
- C. Avoid gaining more than 15 lbs
- D. You should gain more weight because of your condition
Correct answer: B
Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.
4. A nurse is reinforcing teaching to a client with hypertension. What lifestyle change should be emphasized?
- A. Increase intake of sodium-rich foods
- B. Limit intake of high-fat foods
- C. Reduce intake of caffeinated beverages
- D. Eat high-protein foods to lower blood pressure
Correct answer: B
Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to limit the intake of high-fat foods. High-fat foods can contribute to high blood pressure, so reducing their consumption is important in managing hypertension. Choice A is incorrect because increasing intake of sodium-rich foods can worsen hypertension due to their effect on blood pressure. Choice C is incorrect as caffeinated beverages can also elevate blood pressure. Choice D is incorrect because while high-protein foods can be beneficial, they do not directly lower blood pressure like reducing high-fat foods would.
5. How should a healthcare provider manage a patient with Type 1 diabetes?
- A. Administer insulin and monitor blood glucose levels
- B. Provide a low-carbohydrate diet and oral hypoglycemics
- C. Administer oral hypoglycemics and provide dietary education
- D. Provide a high-protein diet and insulin injections
Correct answer: A
Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.
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