Nokea
A client with a history of chronic heart failure is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Weigh yourself daily and report a weight gain of 2 pounds or more in a day.
- B. Restrict fluid intake to 2000 mL per day.
- C. Increase your salt intake to prevent electrolyte imbalance.
- D. Exercise vigorously at least three times a week.
Correct Answer: A
Rationale: The correct answer is to weigh yourself daily and report a weight gain of 2 pounds or more in a day. This instruction is crucial because daily weights help in early detection of fluid retention, a common complication in heart failure. Monitoring weight is essential for managing heart failure and preventing exacerbations. Choice B is incorrect because fluid restriction may be necessary in some cases of heart failure, but a general limit of 2000 mL per day is not appropriate without individual assessment. Choice C is incorrect as increasing salt intake can worsen fluid retention and exacerbate heart failure symptoms. Choice D is incorrect because while exercise is beneficial for heart health, vigorous exercise may not be suitable for all heart failure patients and should be tailored to their specific condition.
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Over-the-counter drugs that are safe to use include:
- A. Acetaminophen
- B. Aspirin
- C. Ibuprofen
- D. All of the above
Correct Answer: D
Rationale: Choice D is correct because acetaminophen, aspirin, and ibuprofen are safe OTC options for pain/fever when used per guidelines, with well-established profiles. Choice A is incorrect alone as it's one drug. Choice B is wrong by itself because aspirin is just part. Choice C is incorrect solo since ibuprofen is only one option.
The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?
- A. Urine specific gravity of 1.03
- B. Frothy, tea-colored urine
- C. Clay-colored stools
- D. Elevated serum amylase and lipase levels
Correct Answer: D
Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked, and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
- A. Help the client determine ways to increase his fluid intake.
- B. Obtain an appointment for the client to have an eye examination.
- C. Instruct the client to use oxygen at night and increase humidification.
- D. Schedule the client for tests to determine his sensitivity to cat hair.
Correct Answer: A
Rationale: The client's cracked tongue and sunken eyes indicate dehydration. Therefore, the priority nursing intervention is to help the client determine ways to increase his fluid intake. Dehydration can exacerbate the client's emphysema symptoms and lead to further complications. Monitoring and addressing the client's fluid intake is crucial for maintaining his health and well-being. Options B, C, and D are not the immediate priorities in this situation. While an eye examination, oxygen use, and sensitivity tests are relevant aspects of care, addressing dehydration through increased fluid intake takes precedence in this scenario.
What predisposing factor most likely contributed to the proximal end of the femur fracture in a 62-year-old woman who lives alone and tripped on a rug in her home?
- A. Failing eyesight leading to an unsafe environment
- B. Renal osteodystrophy from chronic kidney disease (CKD)
- C. Osteoporosis from declining hormone levels
- D. Cerebral vessel changes causing transient ischemic attacks
Correct Answer: C
Rationale: The most likely predisposing factor contributing to the proximal end of the femur fracture in a 62-year-old woman is osteoporosis resulting from declining hormone levels. Osteoporosis weakens the bones, making them more susceptible to fractures, especially in older adults, particularly women. In this case, the fracture can be attributed to the bone density loss associated with osteoporosis, which is a common concern in postmenopausal women. Choices A, B, and D are less likely to have directly contributed to the femur fracture in this scenario. Failing eyesight may increase the risk of falls but does not directly weaken the bones. Renal osteodystrophy affects bone health but is less common in this age group. Cerebral vessel changes causing transient ischemic attacks are related to vascular issues, not bone strength.
Michael calls the clinic to ask about taking fish oil supplements with his simvastatin prescription. The NP's response is:
- A. Avoid fish oil as it will increase your risk of bleeding.
- B. There are no known interactions; it is safe to take fish oil with simvastatin.
- C. Avoid fish oil as it will decrease the effectiveness of the simvastatin.
- D. Fish oil should only be taken with simvastatin if prescribed by your cardiologist.
Correct Answer: B
Rationale: Choice B is correct because fish oil (omega-3s) and simvastatin both lower triglycerides with no significant interactions; studies show they're safe together, enhancing lipid benefits. Choice A is incorrect as fish oil's bleeding risk is minimal and not amplified by simvastatin. Choice C is wrong because fish oil doesn't reduce simvastatin's efficacy—they're complementary. Choice D is incorrect since no prescription is needed for this safe combination.