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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 parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?
- A. Provide decubitus ulcer care and apply a dry dressing
- B. Bathe and feed a client on bed rest
- C. Oral suctioning of an unresponsive elderly client
- D. Teaching a family intermittent (bolus) feedings via G-tube before discharge
Correct Answer: D
Rationale: Teaching a family intermittent (bolus) feedings via G-tube before discharge. Initial teaching cannot be delegated to a UAP or a PN and must be done by RNs.
The nurse is caring for a client with bulimia nervosa. It would be a priority for the nurse to
- A. place limits on the time allowed for client meals
- B. check on the client at irregular intervals during the overnight hours
- C. monitor the client for 1 to 2 hours after each meal
- D. discuss complications associated with bulimia nervosa with the client
Correct Answer: C
Rationale: Monitoring for 1-2 hours after meals (C) prevents purging, a priority in bulimia management. Time limits (A) may increase anxiety, overnight checks (B) are less relevant, and discussing complications (D) is educational but not immediate.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.