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A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?
- A. Peripheral edema
- B. Jugular vein distention
- C. Hepatomegaly
- D. Crackles in the lungs
Correct Answer: D
Rationale: The correct answer is D: Crackles in the lungs. Left-sided heart failure leads to fluid accumulation in the lungs, causing crackles on auscultation. This indicates pulmonary congestion. Peripheral edema (A) is more common in right-sided heart failure. Jugular vein distention (B) is typically seen in right-sided heart failure due to increased venous pressure. Hepatomegaly (C) is more common in conditions like liver disease, not specifically left-sided heart failure.
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When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
- A. Administer prescribed antibiotics on time.
- B. Encourage the client to use a tissue when coughing.
- C. Place the client in a private room.
- D. Perform hand hygiene before and after client contact.
Correct Answer: D
Rationale: The correct answer is D because performing hand hygiene before and after client contact is crucial in preventing the spread of infection in pneumonia. This intervention helps in reducing the transmission of infectious agents from one client to another and from surfaces to clients. It is a fundamental infection control measure that minimizes the risk of spreading pathogens. Option A is important for treating the infection but does not directly prevent its spread. Option B is a good practice to contain respiratory secretions but may not be as effective as hand hygiene. Option C isolates the client but does not address the primary mode of transmission through contaminated hands.
A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation & hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, influencing their respiratory status. The healthcare professional needs to assess potential respiratory risks in the client's environment.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference is more relevant for assessing risk of obstructive sleep apnea rather than overall respiratory status.
C: Height & weight are important for assessing overall health and potential respiratory issues like obesity, but not as immediate as assessing respiratory hazards in the client's daily activities.
Bob reports chest pains when performing strenuous work. The pain goes away when he sits. What is he likely to be experiencing?
- A. Indigestion.
- B. Stable angina.
- C. Unstable angina.
- D. Prinzmetal's angina.
Correct Answer: B
Rationale: Stable angina occurs during physical exertion and resolves with rest.
When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)
- A. Cost-saving measures
- B. Nurse's expertise
- C. Client preferences
- D. Research findings
Correct Answer: A
Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.
Identify what short-term evaluation technique is appropriate to assess whether the patient has met the following learning goals.
- A. Demonstration
- B. Verbalization
- C. Selection
- D. Observation
Correct Answer: B
Rationale: Each learning goal requires a different evaluation technique: Demonstration for subcutaneous insulin injection, Verbalization for identifying side effects of Coumadin, Selection for choosing potassium-rich foods, Observation for verbalizing no shortness of breath, and Verbalization for stating readiness to change a dressing. The correct technique depends on the specific goal.