A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
"I may thicken gravies with cornstarch as I cook."
"Fresh fruits make a good snack option."
"I may eat 2 cans of soup a day."
"I will replace table salt with dried herbs."
The Correct Answer is C
A. Thicken gravies with cornstarch is acceptable as it does not add significant sodium and can be a healthier alternative to flour or other thickening agents.
B. Fresh fruits are indeed a healthy snack option and are encouraged in a heart-healthy diet due to their low sodium and high fiber content.
C. Eating 2 cans of soup a day is concerning because many canned soups are high in sodium, which can exacerbate hypertension. This statement indicates a need for further teaching about sodium intake.
D. Replacing table salt with dried herbs is a positive change that promotes flavor without adding sodium, aligning with heart-healthy dietary recommendations.
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Correct Answer is D
Explanation
A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.
Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.