🔵 Turkey is generally a lean protein choice and is lower in saturated fat than many processed or high-fat meats.

🔵 For a client with hypertension, the nurse should encourage foods that support heart health and help reduce cardiovascular risk.

🔵 Lean meats such as turkey can fit well into a diet such as the DASH diet, which is commonly recommended for blood pressure control.

🔵 Choosing lower-fat protein sources helps decrease excess intake of sodium, cholesterol, and saturated fat when compared with many processed fast foods.

🔵 For this reason, turkey is the best food choice for a client who has hypertension.

Red meat

🔵 Red meat is often higher in saturated fat, which can contribute to cardiovascular disease.

🔵 Clients with hypertension are usually encouraged to limit high-fat meats and choose leaner protein sources instead.

Pizza

🔵 Pizza is commonly high in sodium, saturated fat, and processed ingredients.

🔵 Excess sodium intake can worsen high blood pressure and increase fluid retention.

Black tea

🔵 Black tea contains caffeine, which can temporarily raise blood pressure in some individuals.

🔵 It is not the best dietary recommendation when the question is asking for a helpful food to include for hypertension management.

"Let's talk about your mom's cancer and how things will progress from here.":

🟣 This response is therapeutic because it opens the door to a honest, supportive discussion about the client’s condition and expected progression.

🟣 Family members often need clear information to help them cope and communicate effectively with their loved one.

🟣 By inviting discussion, the nurse encourages anticipatory guidance and emotional preparation.

🟣 This response avoids false reassurance and promotes understanding of the hospice process.

🟣 Therefore, this is an appropriate nursing response.

"You sound like you have questions about your mom dying. Let's talk about it.":

🟣 This statement acknowledges the daughter’s concern and uses therapeutic communication to encourage expression.

🟣 It validates her feelings without judgment and invites further conversation.

🟣 The nurse is helping the daughter process fear and uncertainty in a supportive way.

🟣 Open-ended therapeutic responses are appropriate when families are coping with end-of-life issues.

🟣 For this reason, this response is appropriate.

"Tell me how you are feeling about your mom dying.":

🟣 This response encourages the daughter to explore and verbalize her emotions, which is an important part of coping.

🟣 It is open-ended, supportive, and centered on the daughter’s emotional needs.

🟣 Allowing family members to express grief, fear, or sadness can reduce anxiety and improve communication.

🟣 The nurse is not giving advice too quickly but instead facilitating healthy emotional expression.

🟣 Therefore, this is an appropriate response.

"Tell her not to worry. She still has plenty of time left."

🟣 This response offers false reassurance, which is not therapeutic.

🟣 The nurse should not make promises or assumptions about how much time the client has left.

"Hospice will take good care of your mom, so I wouldn't worry about that."

🟣 This response minimizes the daughter’s feelings by telling her not to worry.

🟣 Therapeutic communication should acknowledge concerns and invite discussion rather than dismiss emotional distress.

💠 Pertussis is a communicable disease that is reportable to public health authorities because of its potential for outbreak and transmission.

💠 Reporting allows the health department to conduct surveillance, contact tracing, and prevention efforts.

💠 Early reporting is especially important because pertussis can be severe, particularly in infants and vulnerable populations.

💠 Community protection depends on timely identification and public health follow-up.

💠 Therefore, a positive pertussis result should be reported to the local health department.

Herpes simplex virus I positive (expected: negative)

💠 Herpes simplex virus type 1 is not typically a routinely reportable communicable disease in this context.

💠 Although it is infectious, it does not usually require mandatory reporting to the health department like pertussis.

Rotavirus positive (expected: negative)

💠 Rotavirus can cause gastrointestinal illness, but it is not the best answer among these options for routine local health department reporting.

💠 In this setting, pertussis is the more clearly recognized reportable disease.

Group A beta-hemolytic streptococcus positive (expected: negative)

💠 Group A beta-hemolytic streptococcus infections are clinically important, but they are not generally reportable in the same routine public health manner as pertussis.

💠 The nurse should prioritize reporting the infection with stronger outbreak-control implications.

🔶 Feeling shaky and weak can indicate hypoglycemia, which requires prompt treatment with a fast-acting carbohydrate.

🔶 Half a cup (4 oz) of fruit juice is an appropriate source of quick sugar to raise the blood glucose level.

🔶 This follows the standard teaching for managing mild hypoglycemia in conscious clients.

🔶 After treatment, the client should recheck glucose if possible and follow up with another snack if needed.

🔶 Therefore, this statement shows correct understanding of diabetes self-management teaching.

"I will soak my feet in water before applying lotion between my toes."

🔶 Clients with diabetes should not soak their feet, because soaking can dry and damage the skin.

🔶 Lotion should also not be applied between the toes, since excess moisture there can promote infection.

"I will only go without socks and shoes when I am in my home."

🔶 Clients with diabetes should avoid going barefoot, even inside the home.

🔶 Walking without socks or shoes increases the risk for unnoticed injury and foot ulcers.

"I will skip a snack if I'm not hungry after lunch."

🔶 Clients taking insulin may need planned meals and snacks to avoid hypoglycemia.

🔶 Skipping a snack without considering insulin timing or blood glucose can be unsafe.

"Wash your feet daily with warm water and soap."

✅ Clients with diabetes should wash their feet daily to reduce dirt, bacteria, and risk of infection.

✅ The water should be warm, not hot, because diabetic neuropathy may reduce the ability to sense temperature accurately.

✅ Gentle cleansing helps maintain skin integrity and promotes early recognition of cuts, redness, or swelling.

✅ Clean feet are an essential part of preventing ulcers and complications.

✅ Therefore, washing the feet daily with warm water and soap is correct teaching.

"Alternate the shoes you wear each day."

✅ Alternating shoes helps reduce pressure points and allows shoes to dry out fully between uses.

✅ This can help prevent skin breakdown, irritation, and moisture buildup.

✅ Clients with diabetes are at higher risk for foot injury and infection, so footwear care is very important.

✅ Wearing different shoes also gives the client an opportunity to inspect each pair for rough seams or foreign objects.

✅ Therefore, alternating shoes each day is an appropriate instruction.

"Apply synthetic fabric socks."

✅ Socks made from certain synthetic blends can help wick moisture away from the feet better than some other materials.

✅ Keeping the feet dry helps reduce friction, skin breakdown, and fungal growth.

✅ Proper socks should fit well, be clean, and avoid tight elastic bands that impair circulation.

✅ Moisture control is especially important for clients who have diabetes and may be prone to skin injury.

✅ Therefore, wearing appropriate synthetic fabric socks is a correct teaching point.

"Wear open-toe shoes."

✅ Clients with diabetes should wear closed-toe, well-fitting shoes to protect their feet from injury.

✅ Open-toe shoes expose the feet to trauma, cuts, and pressure injury.

"Soak your feet for 1 hour each day."

✅ Clients with diabetes should avoid prolonged foot soaking because it can dry and weaken the skin.

✅ Skin breakdown increases the risk of infection and ulcer formation.

💎 Eating vegetables directly from the field may expose the client to pesticides, chemicals, soil contaminants, or infectious organisms if the produce has not been washed properly.

💎 Farmworkers can have increased occupational exposure to agricultural chemicals, making this practice a significant health risk.

💎 Unwashed produce may also carry bacteria or parasites from soil, animals, or contaminated irrigation sources.

💎 Safe food hygiene is essential in reducing both toxic and infectious exposure.

💎 Therefore, this statement indicates a possible health risk and requires further teaching.

"I wear a hat and long sleeves while I am working."

💎 Wearing a hat and long sleeves is a protective behavior that can reduce sun exposure and help limit skin contact with environmental irritants.

💎 This statement does not suggest a health risk; it reflects safe work habits.

"I am currently sharing my home with two roommates."

💎 Sharing a home with two roommates does not automatically indicate a health risk by itself.

💎 This statement would require more context before it could be considered unsafe.

"My home has running water and electricity."

💎 Having running water and electricity suggests that important basic living needs are being met.

💎 This does not indicate an immediate health risk and may actually support safer living conditions.

Add water to the water seal chamber as it evaporates.

🔷 The water-seal chamber must contain the prescribed amount of sterile water to maintain an effective one-way seal.

🔷 This seal allows air to escape from the pleural space while preventing air from reentering the chest.

🔷 If water evaporates and the level drops too low, the drainage system may no longer function properly.

🔷 Maintaining the correct water level helps promote lung re-expansion and protects the client from complications such as pneumothorax.

🔷 For this reason, the nurse should add water to the water-seal chamber as it evaporates according to the manufacturer’s guideline.

Mark the drainage output on the collection chamber.

🔷The nurse should mark the drainage level on the collection chamber at regular intervals to monitor the amount and trend of drainage.

🔷This helps identify whether output is increasing, decreasing, or suddenly changing, which can signal improvement or complications.

🔷Accurate monitoring of chest tube drainage is essential for evaluating the client’s status after chest trauma or thoracic surgery.

🔷Marking the chamber also improves communication among caregivers by providing a visible record of fluid accumulation over time.

🔷Therefore, marking the drainage output on the collection chamber is an appropriate nursing intervention.

Maintain the collection chamber above the level of the client's waist.

🔷The collection chamber should be kept below the level of the client’s chest, not above the waist or chest level.

🔷Keeping the drainage system below the chest uses gravity to promote drainage and helps prevent backflow into the pleural space.

Clamp the chest tube every 2 hr to assess the amount of drainage.

🔷Chest tubes should not be clamped routinely, because clamping can cause pressure to build up in the pleural space.

🔷This can lead to a tension pneumothorax or impaired drainage, making the practice unsafe unless specifically prescribed for a brief purpose.

Strip the chest tube vigorously to dislodge blood clots.

🔷The nurse should not strip the chest tube vigorously, because this creates high negative pressure in the system.

🔷Excessive negative pressure can damage tissue and does not represent safe routine chest tube care.

Instruct the client to perform diaphragmatic breathing.

🔴Diaphragmatic breathing helps improve ventilation by promoting deeper, more efficient breathing and reducing the work of accessory muscles.

🔴This technique is especially helpful for clients who have chronic obstructive pulmonary disease (COPD) manifestations such as wheezing, productive cough, dyspnea, and prolonged smoking history.

🔴It helps the client move air more effectively, decrease air trapping, and improve oxygenation when used along with pursed-lip breathing.

🔴Teaching controlled breathing techniques also helps reduce anxiety, which can worsen shortness of breath.

🔴Therefore, the nurse should include diaphragmatic breathing in the plan of care.

Assess the client's breath sounds.

🔴Ongoing assessment of breath sounds is essential to evaluate airway movement, mucus accumulation, and the client’s response to bronchodilator therapy.

🔴This client initially had crackles and wheezing, so the nurse needs continued auscultation to determine whether treatment is improving ventilation.

🔴Breath sound assessment can also help identify worsening obstruction, retained secretions, or other complications.

🔴Since the client received albuterol, oxygen, and ipratropium, reassessment is necessary to judge the effectiveness of these interventions.

🔴For this reason, the nurse should assess the client's breath sounds.

Perform chest percussion and vibration.

🔴Chest percussion and vibration help loosen and mobilize respiratory secretions, which is beneficial for a client with a productive cough.

🔴 This client has mucus production, wheezing, and crackles, all of which suggest retained secretions contributing to impaired airway clearance.

🔴Mobilizing secretions can make coughing more effective and improve gas exchange.

🔴These interventions are often useful when secretions are difficult to clear through coughing alone.

🔴Therefore, the nurse should include chest percussion and vibration in the plan of care.

Restrict the client's fluid intake.

🔴Clients with thick respiratory secretions usually benefit from adequate hydration, which helps thin mucus and makes it easier to expectorate.

🔴Restricting fluids can worsen secretion retention unless there is another condition requiring fluid limitation.

Increase oxygen flow rate to 4 L/min.

🔴The provider prescribed oxygen at 2 L/min via nasal cannula, and the client’s oxygen saturation improved from 87% to 92% with treatment.

🔴The nurse should not independently increase the oxygen flow above the prescribed rate without a new prescription or clear clinical indication.

Place the client in a supine position.

🔴 A supine position can make breathing more difficult by limiting chest expansion and promoting secretion pooling.

🔴 Clients with dyspnea usually breathe better in an upright or semi-Fowler’s position, which supports lung expansion.