Nokea
A client with a history of heart failure has bilateral +4 edema of her right ankle that extends up to midcalf. She is sitting out of bed and has her legs in a dependent position. Which of the following goals is the priority?
- A. Decrease venous congestion
- B. Maintain normal respirations
- C. Maintain body temperature
- D. Prevent injury to lower extremities
Correct Answer: A
Rationale: Bilateral edema in heart failure results from increased venous pressure and congestion due to impaired cardiac output. The priority goal is to decrease venous congestion (e.g., by elevating legs or using compression) to reduce edema and improve circulation. Respirations, temperature, and injury prevention are secondary in this context.
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The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?
- A. Elevated carbon dioxide level.
- B. Hypoxia not responsive to oxygen therapy.
- C. Metabolic acidosis.
- D. Severe, unexplained electrolyte imbalance.
Correct Answer: B
Rationale: Hypoxia unresponsive to oxygen therapy is an early ARDS sign due to impaired gas exchange. Elevated CO2, metabolic acidosis, and electrolyte imbalances occur later or are unrelated.
The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply.
- A. Addison's disease will resolve over a few weeks, requiring no further treatment.
- B. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
- C. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician.
- D. A medical identification bracelet should be worn.
- E. Family members need to be informed about the warning signals of adrenal crisis.
- F. Dental work or surgery will require adjustment of daily medication.
Correct Answer: B,C,D,E,F
Rationale: Addison's is chronic, requiring lifelong management. Stress management, symptom reporting, medical ID, family education, and medication adjustments for procedures are critical.
A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.