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A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
- A. Frothy, pink sputum
- B. Jugular vein distention
- C. Weight gain
- D. Bradypnea
Correct Answer: A
Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.
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A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which result is reportable?
- A. Herpes simplex
- B. Human papillomavirus
- C. Candidiasis
- D. Chlamydia
Correct Answer: D
Rationale: Chlamydia is a reportable sexually transmitted infection. Reporting cases of Chlamydia to the health department is crucial for disease surveillance, contact tracing, and implementing public health interventions. Herpes simplex, human papillomavirus, and candidiasis are not typically reportable infections, as they do not pose the same public health risks as Chlamydia.
A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct Answer: A
Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.
A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication using a tuberculin syringe
- B. Administer the medication at a 45-degree angle
- C. Use the dorsogluteal muscle for injection
- D. Aspirate for blood return before injecting the medication
Correct Answer: D
Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will monitor my blood sugar level once a week.
- B. I will exercise every day even if my blood sugar is low.
- C. I will eat snacks rich in carbohydrates if my blood sugar drops.
- D. I will avoid sugary foods to prevent my blood sugar from rising.
Correct Answer: C
Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.
A nurse is preparing to administer medications to a client who has a nasogastric (NG) tube. Which of the following actions should the nurse take first?
- A. Check for tube placement.
- B. Flush the NG tube with 0.9% sodium chloride.
- C. Administer the medications as a bolus.
- D. Dissolve the medications in 30 mL of sterile water.
Correct Answer: A
Rationale: The correct first action for the nurse to take when preparing to administer medications to a client with a nasogastric (NG) tube is to check for tube placement. This step is crucial to ensure that the NG tube is correctly positioned in the stomach and not in the respiratory tract, reducing the risk of aspiration. Flushing the NG tube with 0.9% sodium chloride, administering the medications as a bolus, or dissolving the medications in sterile water should only be done after confirming the proper placement of the NG tube. Therefore, options B, C, and D are incorrect as they precede the essential step of verifying tube placement.