A client with heart failure says to the nurse, 'I don't see why I have to watch what I eat because my heart is already damaged.' Which nursing response promotes the client's health?

Correct Answer: A

Rationale: For a heart failure client doubting diet's role, the nurse promotes health by explaining its benefits watching food intake, like limiting sodium, reduces fluid buildup, easing heart strain and cutting hospital trips. This tertiary prevention approach manages the condition, improving quality of life despite damage, aligning with nursing's focus on empowerment through education. Agreeing diet doesn't matter dismisses evidence low-sodium diets improve outcomes. Suggesting food freedom with meds ignores synergy between diet and drugs. Blaming past diet shames without motivating. The positive response ties behavior to tangible gains less dyspnea, more energy encouraging adherence. Studies show dietary control slashes readmissions, making this nursing reply a practical, hopeful nudge toward self-care, vital for chronic illness management.

Correct Answer: C

Rationale: Monitoring oxygen saturation continuously (C) ensures the prescribed oxygen concentration is effective, allowing real-time adjustments to maintain target SpO2. Hourly RR (A) is indirect. Q4h flow checks (B) miss immediate issues. Snug mask (D) aids fit, not concentration. Continuous SpO2, per nursing protocols, guides safe delivery.

Correct Answer: C

Rationale: Constipation frequently affects immobile patients as reduced movement slows peristalsis and increases intestinal water absorption, hardening stool. This disruption in bowel function is a well-documented outcome of limited physical activity, requiring nursing interventions like hydration or laxatives. Appetite doesn't typically rise with immobility, nor does peristalsis speed up it diminishes. Diarrhea isn't a standard effect unless other factors intervene. Nurses tackle this to restore regularity, understanding that immobility's impact on digestion underscores the need for proactive gastrointestinal care in such patients.

Correct Answer: A

Rationale: Signing a care plan agreement is a contract (A) legally binding, per definition. Verbal (B) lacks formality, fidelity (C) promises, advocacy (D) rights not signed. A fits mutual consent, making it correct.

Correct Answer: A

Rationale: In obstetrics, the denominator is the fetal part defining presentation. In breech (buttocks down), the sacrum (choice A) is the reference point, determining positions (e.g., sacroanterior). Femur (choice B), shoulder (choice C), or leg (choice D) aren't denominators; legs vary in flexed/extended breech but don't define it. A is correct, per standard fetal positioning. Nurses monitor breech risks (e.g., cord prolapse), assist in version or cesarean planning, and support safe delivery.

Correct Answer: B

Rationale: A wet dressing from water spill requires removal and replacement to prevent infection and maintain a healing environment. Reinforcing keeps moisture, drying with a hairdryer risks burns or contamination, and air drying is slow and ineffective. This action ensures wound integrity, a core nursing responsibility.

Correct Answer: B

Rationale: Therapeutic touch is use of hands to promote healing (B), per holistic nursing e.g., energy balance. Not surgery (A), not verbal (C), not diagnostic (D) non-invasive. B best defines its healing intent, making it correct.

Correct Answer: B

Rationale: One teaspoon (5 ml) equals approximately 60 drops (gtts), based on standard drop size.

Correct Answer: A

Rationale: Exercising to relieve stress is adaptive coping (A) effective, healthy response, per coping theory. Maladaptive (B) harms (e.g., drinking), risk factor (C) predisposes, illness (D) disease not coping. A improves well-being, making it correct.