Nokea
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
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The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
- A. Administer PRN albuterol by nebulizer
- B. Assist with guided imagery to relieve anxiety
- C. Elevate the head of the bed
- D. Give PRN sublingual morphine
Correct Answer: C
Rationale: Elevating the head of the bed (C) is the first non-pharmacologic intervention to ease breathing in heart failure by reducing pulmonary congestion. Albuterol (A) is for bronchospasm, imagery (B) is secondary, and morphine (D) is for severe distress.