Nokea
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
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During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.
A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding?
- A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2
- B. Small amount of non-formed stool in the colostomy bag on postoperative day 6
- C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3
- D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5
Correct Answer: D
Rationale: A gray-tinged stoma suggests ischemia or poor perfusion, which is a critical finding requiring immediate reporting to assess for stoma viability.
When caring for a client with hypocalcaemia, the nurse should assess for:
- A. A decreased level of consciousness
- B. Tetany
- C. Bradycardia
- D. Respiratory depression
Correct Answer: B
Rationale: Hypocalcemia can cause tetany (muscle spasms or twitching) due to increased neuromuscular excitability.
The nurse is reviewing prescriptions for assigned adult clients. The nurse should question the prescription for
- A. 0.45% sodium chloride for a client with syndrome of inappropriate antidiuretic hormone secretion who has a decreased sodium level
- B. 0.9% sodium chloride for a client with gastrointestinal bleeding who has a decreased hemoglobin level
- C. 1,000 mL bolus of 0.9% sodium chloride for a client with septic shock who has an increased WBC count
- D. lactated Ringer solution for a client with hypovolemic shock and a thermal burn who has an increased hematocrit level
Correct Answer: A
Rationale: 0.45% sodium chloride is hypotonic and can worsen hyponatremia in SIADH by further diluting serum sodium, requiring clarification for a hypertonic solution.