Nokea
A client with a history of heart failure is admitted with dyspnea. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure.
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Communicating with parents and children about health care has become increasingly significant because:
- A. Consumers of health care cannot keep up with rapid advances in science.
- B. The influence of the media and specialization have increased the complexity of managing health.
- C. Nurse educators have recognized the value of communication.
- D. Clients are more demanding that their rights be respected.
Correct Answer: B
Rationale: Media influence and medical specialization have increased healthcare complexity, making clear communication essential to ensure understanding and informed decision-making.
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
- A. Draw the shades closed.
- B. Provide the client access to a bedpan.
- C. Turn the volume on the television down.
- D. Instruct the client not to get out of bed without assistance.
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
- A. Nightingale agitation
- B. Extrapyramidal side effects
- C. Vomiting
- D. Anticholinergic side effects
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. The nurse should administer which of the following as prescribed?
- A. Oxygen at 2 L/min via nasal cannula.
- B. Albuterol via nebulizer.
- C. Furosemide intravenously.
- D. Morphine for respiratory distress.
Correct Answer: A, B
Rationale: Low-flow oxygen (2 L/min) and albuterol relieve hypoxemia and bronchospasm in COPD exacerbation.
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.