Nokea
A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:
- A. Administering diuretics
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.
You may also like to solve these questions
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:
- A. Fewer alveoli, slower respiratory rate
- B. Diaphragmatic breathing, larger volume of air
- C. Larger number of alveoli, diaphragmatic breathing
- D. Rounded shape of chest, smaller volume of air
Correct Answer: D
Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (C) is not typically required unless in a sterile procedure.
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis:
- A. Is caused by poor physical conditions or poor nutrition
- B. Often results from unhygienic conditions or an unclean environment
- C. Is directly related to sluggish circulation in the affected limb
- D. May develop from sinuses in the involved bone that retain infectious material
Correct Answer: D
Rationale: Areas of sequestrum may be surrounded by dense bone, become honeycombed with sinuses, and retain infectious organisms for a long time, leading to chronic osteomyelitis exacerbation.