Nokea
A long-term-care resident with venous stasis ulcers is treated with Unna's boot. Which of the nursing activities included in the resident's care is best for you to delegate to a nursing assistant?
- A. Monitor capillary perfusion once every 8 hours.
- B. Teach family members the signs of infection.
- C. Evaluate foot sensation and movement each shift.
- D. Assist patient with cleaning around Unna's boot.
Correct Answer: D
Rationale: Cleaning around the boot is a simple task suitable for a nursing assistant.
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The client is receiving intravenous dopamine. What is the most important nursing assessment?
- A. Monitor heart rate and rhythm
- B. Monitor blood pressure
- C. Monitor respiratory rate
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is A: Monitor heart rate and rhythm. Dopamine is a medication that can affect the heart rate and rhythm. Monitoring these parameters is crucial to detect any potential adverse effects such as tachycardia or arrhythmias. Monitoring blood pressure is also important, but assessing heart rate and rhythm takes precedence due to the direct impact of dopamine on cardiac function. Respiratory rate and oxygen saturation are generally not directly affected by dopamine administration.
In third-degree atrioventricular block, all sinus impulses fail to activate the ventricles. This will be detected by
- A. A highly variable PR interval
- B. Regular PP intervals
- C. A slow heart rate
- D. Regular RR intervals
Correct Answer: C
Rationale: Slow heart rate reflects lack of conduction from atria to ventricles.
What is a type of pneumonia that is contracted by inhaling contaminated water droplets?
- A. Legionnaires' disease
- B. Tuberculosis
- C. Asbestosis
- D. Histoplasmosis
Correct Answer: A
Rationale: The correct answer is A: Legionnaires' disease. Legionnaires' disease is caused by inhaling water droplets contaminated with Legionella bacteria. These bacteria thrive in warm water, such as in air conditioning systems and hot tubs. The symptoms of Legionnaires' disease include high fever, cough, and shortness of breath.
B: Tuberculosis is caused by Mycobacterium tuberculosis and is transmitted through the air when an infected person coughs or sneezes.
C: Asbestosis is a lung disease caused by inhaling asbestos fibers, not contaminated water droplets.
D: Histoplasmosis is a fungal infection caused by inhaling spores found in soil with bird or bat droppings, not contaminated water droplets.
What is a condition where the heart's ability to pump blood is reduced because the heart muscle is enlarged, thickened, or stiffened?
- A. Cardiomyopathy
- B. Endocarditis
- C. Myocarditis
- D. Aortic stenosis
Correct Answer: A
Rationale: The correct answer is A: Cardiomyopathy. Cardiomyopathy refers to a condition where the heart muscle is enlarged, thickened, or stiffened, leading to a reduced ability to pump blood effectively. This condition directly relates to the heart's structural changes, impacting its pumping function. Endocarditis (B) is an infection of the heart's inner lining, not directly related to heart muscle changes. Myocarditis (C) is inflammation of the heart muscle but does not necessarily involve structural changes leading to reduced pumping ability. Aortic stenosis (D) is a condition where the heart's aortic valve is narrowed, impeding blood flow, but it does not specifically refer to the heart muscle changes seen in cardiomyopathy.
What is the condition where the lungs become filled with fluid, often due to heart failure, making it difficult to breathe?
- A. Pulmonary edema
- B. Pleural effusion
- C. Pulmonary hypertension
- D. Pneumothorax
Correct Answer: A
Rationale: Step-by-step rationale:
1. Pulmonary edema is the condition where lungs fill with fluid due to heart failure, causing breathing difficulty.
2. Pleural effusion is fluid accumulation in the pleural space, not in the lung tissue.
3. Pulmonary hypertension is high blood pressure in the pulmonary arteries, not related to fluid accumulation.
4. Pneumothorax is the presence of air in the pleural space, not fluid.
Summary:
Pulmonary edema is the correct answer as it specifically describes the condition of fluid accumulation in the lungs due to heart failure, leading to breathing difficulties. Pleural effusion, pulmonary hypertension, and pneumothorax are incorrect as they involve different pathologies not related to lung fluid accumulation.