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A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?
- A. Administer oxygen via non-rebreather mask.
- B. Administer furosemide (Lasix) IV push.
- C. Insert a Foley catheter to monitor urine output.
- D. Position the client in a high Fowler's position.
Correct Answer: A
Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.
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When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
- A. Remind the child to clean his genital area.
- B. Defer perineal care due to the child's age.
- C. Retract the foreskin gently to cleanse the penis.
- D. Inquire about the reason for the child not being circumcised.
Correct Answer: C
Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
- A. Encourage the client to see the clinic's grief counselor.
- B. Determine if the client has a family history of suicide attempts.
- C. Inquire about whether the life partner had AIDS.
- D. Consult with the healthcare provider about the client's need for antidepressant medications.
Correct Answer: A
Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.
The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
- A. Performing ROM exercises during bathing.
- B. Changing the patient's position every two hours.
- C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
- D. Placing the patient in the prone position for one hour three times a day.
Correct Answer: C
Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.
The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)
- A. 0.8 mL
- B. 0.75 mL
- C. 0.7 mL
- D. 0.9 mL
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?
- A. Insert the needle at a 90-degree angle for subQ injections
- B. Aspirate for blood return before injecting the medication
- C. Pinch the skin before inserting the needle
- D. Massage the site after administering the injection
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.