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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Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct Answer: D
Rationale: Occult bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract.
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?
- A. Hand the provider a gown and gloves
- B. Not say anything; it is the HCP's decision
- C. Notify the charge nurse and unit manager
- D. Monitor for increased infections on the unit
Correct Answer: A
Rationale: A: Providing PPE ensures immediate compliance with contact precautions. B: Ignoring the breach risks transmission. C, D: These actions delay intervention.
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.
Which of these findings would the nurse more closely associate with dehydration in a 10 month-old infant?
- A. Status of the eyes and the tongue
- B. Urine output
- C. Skin elasticity
- D. Dietary patterns
Correct Answer: A
Rationale: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.