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A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
- A. Auscultate breath sounds
- B. Check for peripheral edema
- C. Measure the client's vital signs
- D. Review the client's weight log over the past several days
Correct Answer: A
Rationale: Auscultating breath sounds (A) assesses the cause of breathlessness (e.g., pulmonary edema) in heart failure, guiding immediate interventions. Edema (B), vitals (C), and weight (D) are secondary.
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A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
The nurse is talking with a group of parents about puberty. The nurse should include that the first sign of puberty in clients of the male sex is
- A. increased height
- B. greater muscle mass
- C. testicular enlargement
- D. increased length of the penis
Correct Answer: C
Rationale: Testicular enlargement (C) is the first sign of puberty in males, occurring before height increase (A), muscle mass gain (B), or penile growth (D).
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.
The nurse is preparing to give an adult a subcutaneous injection of heparin. What should the nurse check prior to giving the medication?
- A. International normalized ratio (INR)
- B. Bleeding time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: D
Rationale: Partial thromboplastin time (PTT) monitors heparin's anticoagulant effect, ensuring safe administration by assessing bleeding risk.