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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A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that:
- A. Toddlers often misbehave to get the attention of adults.
- B. Toddlers are able to use thought processes to experience events and reactions.
- C. Negative actions that are not immediately punished will be repeated.
- D. Manipulation of objects in their environment enables the toddler to learn about spatial relationships.
Correct Answer: D
Rationale: Toddlers explore spatial relationships through actions like shaking a cup, not necessarily to misbehave. Attention-seeking or punishment is less relevant.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
- A. Expressing feelings of low self-worth
- B. Discussing remorse and guilt for actions
- C. Displaying dependence on others
- D. Expressing anger toward others
Correct Answer: A
Rationale: Clients with severe depression and suicidal ideation often struggle to express feelings of low self-worth , which contributes to their emotional withdrawal. Discussing remorse or dependence may be present but is less central. Expressing anger is more typical in other conditions like bipolar disorder.
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.