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A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?
- A. Weigh yourself at the same time every day.
- B. Use the same scale for weighing each time.
- C. Record your weight in a journal or log.
- D. Report any weight gain of more than 2 to 3 pounds in a day.
Correct Answer: D
Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.
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Which of the following is a priority intervention for a patient with heart failure?
- A. Administering diuretics.
- B. Administering oxygen.
- C. Administering beta-blockers.
- D. Administering vasodilators.
Correct Answer: B
Rationale: Administering oxygen is a priority intervention in heart failure because it helps improve oxygenation, alleviate hypoxemia, and reduce the workload on the heart. Oxygen therapy is crucial in managing acute heart failure exacerbations. While diuretics (Choice A) are commonly used in heart failure to reduce fluid overload, administering oxygen takes precedence due to its immediate impact on oxygen delivery. Beta-blockers (Choice C) and vasodilators (Choice D) are also important in heart failure management, but in the acute setting, ensuring adequate oxygen supply is the priority.
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Inform the healthcare provider of the need for potassium replacement.
- B. Prepare to administer a glucose-insulin-potassium replacement.
- C. Change the plan of care to include hourly urinary output measurement.
- D. Instruct the client to increase daily intake of potassium-rich foods.
Correct Answer: A
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.
Which of the following is a common cause of chronic obstructive pulmonary disease (COPD)?
- A. Smoking
- B. Asthma
- C. Allergies
- D. Chronic bronchitis
Correct Answer: A
Rationale: Smoking is the correct answer as it is a well-established common cause of chronic obstructive pulmonary disease (COPD). Smoking leads to long-term damage to the lungs, contributing to the development of COPD. Choice B, asthma, is not a cause but a separate respiratory condition characterized by airway inflammation and hyperresponsiveness. Allergies, choice C, are not a direct cause of COPD but can exacerbate symptoms in individuals with existing COPD. Chronic bronchitis, choice D, is a type of COPD, not a cause of COPD itself, making it an incorrect choice in this context.
A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Monitoring catheter drainage
- B. Decreasing the flow rate
- C. Irrigating the catheter manually
- D. Discontinuing infusing the solution
Correct Answer: C
Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.
What is the priority intervention for a patient with a suspected myocardial infarction (MI)?
- A. Administering oxygen.
- B. Administering nitroglycerin.
- C. Administering aspirin.
- D. Administering morphine.
Correct Answer: A
Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.