Nokea
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
- A. Check pedal pulses.
- B. Check legs for pitting edema.
- C. Upper extremity neuro checks.
- D. Auscultate lung sounds.
- E. Observe respirations.
- F. Observe for gait disturbances.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
You may also like to solve these questions
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
- A. A recent tick bite
- B. Pharyngitis two weeks ago
- C. A mosquito bite last week
- D. Ingestion of foods high in uric acid
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.
The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.
A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.