Nokea
A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
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A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
- A. Place a cool cloth on the forehead.
- B. Elevate the head of the bed 30 degrees.
- C. Administer morphine 2 mg IV.
- D. Prepare for a lumbar puncture.
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
A nurse admits a client to the emergency department who reports nausea, vomiting, and epigastric pain that worsens when lying down. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
- A. Increased serum amylase
- B. Decreased WBC count
- C. Increased serum calcium
- D. Decreased serum lipase
Correct Answer: A
Rationale: Serum amylase rises quickly in acute pancreatitis due to pancreatic inflammation.
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A client is receiving continuous enteral nutrition through a nasogastric small-bore silicone feeding tube. What should the nurse plan for when this client has a computed tomography (CT) scan ordered?
- A. Ask the healthcare provider to re-schedule the scan
- B. Send a suction catheter with the client in case of aspiration during the scan
- C. Shut the feeding off 30-60 minutes before the scan
- D. Connect the feeding tube to continuous suction before and during the exam
Correct Answer: C
Rationale: Stopping feeding 30-60 minutes before the scan reduces aspiration risk and prevents stomach contents from interfering with imaging.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Troponin
- B. Aspartate aminotransferase (AST)
- C. Serum amylase
- D. Unconjugated bilirubin
Correct Answer: A
Rationale: Troponin rises within 3-12 hours post-MI and is the most specific marker for myocardial injury.