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A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?
- A. Daily weight
- B. Electrolyte levels
- C. Urine output
- D. All of the above
Correct Answer: D
Rationale: Monitoring daily weight, electrolyte levels, and urine output is crucial in evaluating treatment effectiveness for heart failure. Daily weight monitoring helps assess fluid retention or loss, changes in electrolyte levels can indicate imbalances affecting heart function, and urine output monitoring provides insights into kidney function and fluid balance. Therefore, all options are essential components in assessing the patient's fluid status and response to treatment, making 'All of the above' the correct answer. Choices A, B, and C are incorrect individually as they only represent partial aspects of monitoring heart failure treatment effectiveness.
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What skin care measure should the nurse implement for a client who underwent external radiation treatment the previous day?
- A. Cleanse the radiated area with water and pat the skin dry
- B. Lightly massage the radiated skin with a lanolin-based lotion
- C. Rinse the site with normal saline and cover with a sterile towel
- D. Use a soft washcloth to gently remove the skin markings
Correct Answer: A
Rationale: The correct measure for skin care after external radiation treatment is to cleanse the radiated area with water and pat the skin dry. This gentle cleansing without harsh chemicals or friction helps protect the integrity of radiated skin, preventing irritation or further damage. Choice B is incorrect because massaging radiated skin can cause further irritation, which should be avoided. Choice C is incorrect as rinsing with normal saline and covering with a sterile towel may not be necessary and could potentially introduce infection due to excessive moisture. Choice D is incorrect as using a soft washcloth to remove skin markings can be too abrasive for radiated skin, risking damage and irritation.
The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?
- A. Deltoid muscle
- B. Inner forearm
- C. Abdomen
- D. Thigh
Correct Answer: B
Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.
A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach
- B. Monitor sodium intake
- C. Report any signs of weight gain
- D. Avoid excessive caffeine intake
Correct Answer: B
Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.
The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?
- A. Peripheral edema
- B. Jugular vein distention
- C. Shortness of breath
- D. Weight gain
Correct Answer: C
Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.
A client with a diagnosis of hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide?
- A. Take the medication at bedtime.
- B. Take the medication with food.
- C. Report any symptoms of hyperthyroidism.
- D. Discontinue the medication if you feel well.
Correct Answer: C
Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to report any symptoms of hyperthyroidism. Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate overtreatment or excessive dosing of levothyroxine. Prompt reporting of these symptoms is crucial to prevent serious complications. Choices A and B are not the most critical information related to levothyroxine administration. Instructing the client to take the medication at bedtime or with food can be important for adherence but is not as crucial as monitoring for signs of hyperthyroidism. Choice D is incorrect as discontinuing the medication if feeling well can lead to a relapse of hypothyroidism symptoms.