Nokea
A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
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The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?
- A. Schedule a portable chest x-ray per PRN protocol.
- B. Maintain the current IV antibiotic schedule.
- C. Obtain a specimen of the drainage for culture.
- D. Milk' the tube to remove any clots.
Correct Answer: C
Rationale: A culture of the changed drainage assesses for infection or other causes, prioritizing over imaging, antibiotics, or tube manipulation.
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. Neutrophil count.
- B. C-reactive protein level.
- C. Platelet count.
- D. Serum potassium and sodium levels.
Correct Answer: B
Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.