Nokea
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
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A female client talks to the nurse in the provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am the one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occur more frequently.'
- B. My fibroids are noncancerous tumors that grow slowly.'
- C. My associated problems I have had are pelvic pressure and pain, urinary incontinence, and constipation.'
- D. Fibroids that cause no problems still need to be taken out.'
Correct Answer: D
Rationale: Fibroids that cause no findings may require only 'watchful waiting' with no treatment. Only when the client's findings become disturbing to them would surgical interventions be considered.
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
- A. apply suction for no more than 10 seconds
- B. maintain sterile technique
- C. lubricate 3 to 4 inches of the catheter tip
- D. withdraw catheter in a circular motion
Correct Answer: A
Rationale: Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.
The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
- A. "Persons entering the room with colds should stay at least 3 feet from me."
- B. "My family plans to bring flowers from my garden to help me feel better."
- C. "The precautions will protect me and help my blood count recover faster."
- D. "Persons entering my room should perform hand hygiene before entering."
Correct Answer: D
Rationale: D: Hand hygiene is critical to prevent pathogen introduction. A: Visitors with colds should avoid entry. B: Flowers can harbor microbes. C: Precautions don't improve neutrophil counts.
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous climbing flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.