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A client who has congestive heart failure is being admitted. How should the nurse position this client?
- A. Supine
- B. Sims'
- C. Semi-sitting
- D. Side-lying
Correct Answer: C
Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.
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In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
- A. Cardizem SR tablet (diltiazem)
- B. Lanoxin liquid
- C. Os-cal tablet (calcium carbonate)
- D. Tylenol liquid (acetaminophen)
Correct Answer: A
Rationale: Cardizem SR is a 'sustained-release' drug form. Sustained release (controlled-release, long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute another medication.
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.
The nurse is preparing to give a heparin injection to a client who is severely malnourished and has minimal adipose tissue. Which method of injection would be appropriate for this client?
- A. EX12_Q49_1.PNG
- B. EX12_Q49_2.PNG
- C. EX12_Q49_3.PNG
- D. EX12_Q49_4.PNG
Correct Answer: C
Rationale: For a malnourished client with minimal adipose tissue, heparin should be injected at a 90-degree angle using a 25-gauge needle to ensure subcutaneous delivery without hitting muscle.
A client with Cushing's syndrome should be instructed to:
- A. Avoid alcoholic beverages
- B. Limit the sodium in her diet
- C. Increase servings of dark green vegetables
- D. Limit the amount of protein in her diet
Correct Answer: B
Rationale: A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.
The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
- A. Administer albuterol nebulizer
- B. Assist the client in identifying the trigger and ways to avoid it
- C. Coach the client through controlled breathing exercises
- D. Continue to monitor oxygen saturation
Correct Answer: C
Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.