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Which of the ff symptoms is observed in the client with Right Sided Heart Failure?
- A. Dependent pitting edema
- B. Orthopnea
- C. Exertional dyspnea
- D. Hemoptysis CARING FOR CLIENTS UNDERGOING CARDIOVASCULAR SURGERY
Correct Answer: A
Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.
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While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?
- A. Diphenhydramine hydrochloride (Benadryl)
- B. Guaifenesin (Robitussin)
- C. Pseudoephedrine hydrochloride (Sudafed)
- D. Loperamide (Imodium)
Correct Answer: A
Rationale: Rationale:
A: Diphenhydramine hydrochloride (Benadryl) is an antihistamine commonly used to treat allergic reactions, including those from bee stings. It can help alleviate symptoms like itching and swelling. Keeping Benadryl on hand is crucial for managing an allergic reaction promptly.
Other Choices:
B: Guaifenesin (Robitussin) is an expectorant used to treat coughs, not allergic reactions.
C: Pseudoephedrine hydrochloride (Sudafed) is a decongestant used for nasal congestion, not allergic reactions.
D: Loperamide (Imodium) is an antidiarrheal used to treat diarrhea, not allergic reactions.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: A
Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). This nerve is responsible for hearing and balance. Ringing noises indicate a disturbance in hearing function. The other choices are incorrect because: A: Frontal lobe is associated with executive functions, not hearing. B: Six cranial nerve (abducent) controls eye movement. C: Occipital lobe is related to vision, not hearing. Therefore, the correct choice is D as it directly relates to the symptom described.