Nokea
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Heart murmur
- B. Dependent edema
- C. Chest pain
- D. Crackles in the lungs
Correct Answer: B
Rationale: Dependent edema occurs in right-sided HF due to systemic venous congestion.
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The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A. Topical ointment
- B. Sustained-release
- C. Sublingual
- D. Transdermal patch
Correct Answer: C
Rationale: Sublingual nitroglycerin has the fastest onset (1-3 minutes) due to direct absorption into bloodstream.
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypophosphatemia
Correct Answer: D
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome due to intracellular shifts of phosphorus during refeeding.
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?
- A. Place the client in a sitting position
- B. Examine the client for areas of skin breakdown
- C. Check the client's bladder for distention
- D. Check the client for a fecal impaction
Correct Answer: A
Rationale: Sitting position lowers BP immediately by promoting venous pooling, addressing the hypertensive crisis.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.