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A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?
- A. Presence of ascites
- B. Bilateral lung crackles
- C. Jugular vein distention
- D. Pedal edema bilaterally
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?
- A. Obtain a prescription for pain medication.
- B. Have the client stop and lie back down in bed.
- C. Report the complaint to the healthcare provider.
- D. Instruct the client to continue getting out of bed and into a chair.
Correct Answer: B
Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain.
The LPN/LVN is reinforcing instructions to a client on the use of a metered-dose inhaler. The nurse should recognize that the client is using the inhaler correctly if the client takes which action?
- A. Takes a deep breath and then exhales just before administration
- B. Holds the mouthpiece 1 to 2 inches from the mouth
- C. Inhales the medication and then exhales immediately after administration
- D. Performs 3 short inhalations and then exhales deeply after administration
Correct Answer: A
Rationale: When using a metered-dose inhaler, the client should take a deep breath and then exhale just before administration. This technique helps ensure that the medication is inhaled effectively. By exhaling before administration, the client can fully inhale the medication into the lungs, maximizing its therapeutic effects.
The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?
- A. Wear gloves in cold weather.
- B. Avoid caffeine and chocolate.
- C. Increase intake of vitamin C.
- D. Use a heating pad for warmth.
Correct Answer: A
Rationale: Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode.
While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?
- A. Your doctor expects me to prepare you for this procedure.
- B. That's fine, if that's what you want. I'll call your health care provider.
- C. So you're saying that you want to talk to your health care provider?
- D. I'm concerned with the way you've dismissed me. I know what I am doing.
Correct Answer: C
Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication.
The client at risk for thrombophlebitis receives reinforcement from the LPN/LVN regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
- A. I should avoid sitting for prolonged periods.
- B. I will take frequent walks and avoid prolonged bed rest.
- C. I should drink plenty of fluids to stay hydrated.
- D. I will use compression stockings as advised by my doctor.
Correct Answer: B
Rationale: The correct answer is B. Taking frequent walks and avoiding prolonged bed rest are essential measures to promote circulation and reduce the risk of thrombophlebitis. Physical activity helps prevent blood from pooling and clotting in the veins, thus decreasing the likelihood of thrombophlebitis development.