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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.
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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.
A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first?
- A. Administer oxygen using a high-concentration mask.
- B. Give the client cold fluids orally.
- C. Apply a heating pad to prevent shivering.
- D. Encourage the client to walk to promote circulation.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen using a high-concentration mask. In exertional heat stroke, the body's ability to regulate temperature is compromised, leading to confusion, high temperature, and low blood pressure. Oxygen therapy helps support oxygenation during heat stress. It takes priority to ensure adequate oxygenation and prevent hypoxia, which can worsen the client's condition. Choices B, C, and D are incorrect. Giving cold fluids orally can potentially induce shock in a hypotensive client. Applying a heating pad can lead to further increase in body temperature. Encouraging the client to walk can exacerbate heat stress and increase the risk of collapse.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
- A. Bronchoconstriction
- B. Refractory hypoxemia
- C. Pulmonary hypertension
- D. Pleural effusion
Correct Answer: B
Rationale: Correct Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when its convenient for you.
- C. I can infuse the medication at a faster rate.
- D. I have up to 2 hours after the usual schedule time to give you this medication.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Vancomycin is typically given at specific intervals to maintain therapeutic levels in the bloodstream.
2. Giving the medication 2 hours earlier may lead to suboptimal drug levels.
3. Answer D allows flexibility within the recommended dosing schedule.
4. Answers A, B, and C compromise the effectiveness and safety of vancomycin administration.
5. Option D ensures the medication is given within an appropriate timeframe.