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A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?
- A. Jugular vein distention.
- B. Crackles in the lungs.
- C. Peripheral edema.
- D. Hepatomegaly.
Correct Answer: C
Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.
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When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- A. Loosen the right wrist restraint.
- B. Apply a pulse oximeter to the right hand.
- C. Compare hand color bilaterally.
- D. Palpate the right radial pulse.
Correct Answer: A
Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.
The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.
The client has a chest tube. What is the most important action for the nurse to take?
- A. Ensure the chest tube remains unclamped at all times.
- B. Empty the chest tube every 2 hours.
- C. Keep the drainage system below the level of the chest.
- D. Assess for subcutaneous emphysema.
Correct Answer: C
Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect it upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.