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A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Crackles in the lung bases
- C. Dependent edema
- D. Productive cough
Correct Answer: C
Rationale: Dependent edema is a common finding in clients with pneumonia due to fluid retention and decreased mobility. Bradycardia (Choice A) is not typically associated with pneumonia. Crackles in the lung bases (Choice B) are more commonly heard in conditions like heart failure or pulmonary edema. A productive cough (Choice D) can be seen in pneumonia but is not as specific as dependent edema.
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A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?
- A. I will take warfarin every other day.
- B. I will eat more leafy green vegetables while taking warfarin.
- C. I will use a soft toothbrush while taking warfarin.
- D. I will have my INR checked regularly while taking warfarin.
Correct Answer: B
Rationale: The correct answer is B. Eating more leafy green vegetables can increase vitamin K intake, which may reduce the effectiveness of warfarin. This can lead to fluctuations in the International Normalized Ratio (INR) levels, affecting the medication's efficacy. Choices A, C, and D are correct statements. Taking warfarin every other day, using a soft toothbrush to prevent gum bleeding, and having regular INR checks are all appropriate and important actions when taking warfarin.
What is the primary purpose of administering an antiemetic?
- A. To reduce nausea and vomiting
- B. To increase appetite
- C. To treat nausea caused by chemotherapy
- D. To treat allergic reactions
Correct Answer: A
Rationale: The correct answer is A: 'To reduce nausea and vomiting.' Antiemetics are medications used to prevent or alleviate nausea and vomiting. While they may indirectly help with appetite by reducing the unpleasant symptoms that can lead to decreased food intake, their primary purpose is not to increase appetite (Choice B). Choice C, 'To treat nausea caused by chemotherapy,' is partly correct as antiemetics are commonly used to manage chemotherapy-induced nausea, but this is not their exclusive purpose. Choice D, 'To treat allergic reactions,' is incorrect as antiemetics are not primarily used for treating allergic reactions.
A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct Answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
How should a healthcare professional manage a patient with non-compliance to hypertension medication?
- A. Provide education on medication
- B. Refer the patient to a specialist
- C. Discontinue the medication
- D. Reassess the patient in 6 months
Correct Answer: A
Rationale: Providing education on medication is crucial when managing a patient with non-compliance to hypertension medication. By educating the patient on the importance of adherence, potential side effects, and the impact of uncontrolled hypertension, healthcare professionals can help improve the patient's understanding and compliance. Referring the patient to a specialist (Choice B) may be necessary in some cases but should not be the first step. Discontinuing the medication (Choice C) without exploring reasons for non-compliance and providing education can worsen the patient's condition. Reassessing the patient in 6 months (Choice D) is important but should be accompanied by interventions to address non-compliance in the interim.
A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?
- A. Cleanse the wound with povidone-iodine.
- B. Apply a hydrocolloid dressing.
- C. Perform debridement as needed.
- D. Keep the wound open to air.
Correct Answer: B
Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.