Nokea
A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
- A. Pain related to ischemia
- B. Risk for altered elimination: constipation
- C. Risk for complication: dysrhythmias
- D. Anxiety related to pain
Correct Answer: A
Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.
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What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?
- A. Demonstration of appropriate hand hygiene
- B. Explanation of wound care technique
- C. Review of signs and symptoms of infection
- D. Instructions for when to contact the healthcare provider
Correct Answer: A
Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.
When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?
- A. Fungi
- B. Friction
- C. Nail polish
- D. Nail polish remover
Correct Answer: A
Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.
A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?
- A. Daily weight
- B. Intake and output
- C. Urine specific gravity
- D. Peripheral edema
Correct Answer: A
Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.
A client is being discharged with a prescription for digoxin (Lanoxin). Which of the following instructions should the nurse include in the discharge teaching?
- A. Take your pulse daily before taking this medication.
- B. Take an extra dose if you miss a dose of this medication.
- C. Take this medication with food.
- D. Avoid eating foods high in potassium while taking this medication.
Correct Answer: A
Rationale: The correct answer is A: 'Take your pulse daily before taking this medication.' It is essential for clients taking digoxin to monitor their pulse daily to detect bradycardia, a potential side effect. Choice B is incorrect because clients should never take an extra dose if a dose is missed; they should take the missed dose as soon as remembered unless it is close to the time for the next dose. Choice C is incorrect because digoxin is preferably taken with food to minimize gastrointestinal side effects. Choice D is incorrect because digoxin itself can cause low potassium levels, so avoiding potassium-rich foods is not necessary.
A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
- A. Choose the most distal site on the selected extremity
- B. Apply a cool compress to the selected extremity before insertion of the IV catheter
- C. Stroke the selected extremity before insertion of the IV catheter
- D. Place the tourniquet above the proposed insertion site
Correct Answer: C
Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.