Nokea
A client with a history of heart failure is admitted with jugular vein distension. The nurse should include which of the following in the plan of care?
- A. Administer furosemide as prescribed.
- B. Position the client in Fowler's position.
- C. Restrict sodium intake.
- D. Encourage ambulation.
Correct Answer: A, B, C
Rationale: Furosemide, Fowler's position, and sodium restriction reduce fluid overload in heart failure.
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A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, 'My 6-year-old, Kevin, is starting to act just like his father. I just don't know how to handle this.' Which response by the nurse is most appropriate?
- A. You'll have to limit Kevin's contact with his father.'
- B. Counseling for Kevin would be helpful.'
- C. Most boys outgrow these behaviors.'
- D. Setting limits on his behavior is all you need to do now.'
Correct Answer: B
Rationale: Counseling can help address behavioral issues potentially stemming from trauma or modeling, providing professional support for the child.
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
Select the sound that is heard with percussion with its description.
- A. Tympany: A hollow sound
- B. Dullness: A thud like sound
- C. Dullness: A hollow sound
- D. Resonance: A booming sound
Correct Answer: A,B,D
Rationale: Tympany is a hollow sound (e.g., over air-filled structures like the stomach), dullness is a thud-like sound (e.g., over solid organs like the liver), and resonance is a booming sound (e.g., over lung tissue). Option C is incorrect because dullness is not a hollow sound.
A client is being treated with I.V. fluids for hypovolemic shock. Which of the following values is the best indicator that fluid resuscitation has been effective?
- A. Urine output of 30 mL/hour.
- B. Systolic blood pressure of 90 mm Hg.
- C. Respiratory rate of 22 breaths/minute.
- D. Pulse rate of 110 bpm.
Correct Answer: A
Rationale: A urine output of 30 mL/hour indicates adequate renal perfusion, a key sign of effective fluid resuscitation in hypovolemic shock.
The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
- A. CQI processes are required by accrediting agencies
- B. The approach to CQI can be retrospective or concurrent
- C. Institutional Review Board (IRB) approval is required
- D. CQI is conducted by people who are not part of the process
- E. The CQI process has a fixed endpoint
Correct Answer: A,B
Rationale: CQI is often required by accrediting agencies and can be retrospective or concurrent. IRB approval is not typically needed, CQI involves unit staff, and it is ongoing without a fixed endpoint.