Nokea
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.)
- A. Excessive somnolence
- B. Epistaxis
- C. Pink frothy sputum
- D. Tachypnea
- E. Urinary frequency
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.
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A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: Rationale: A client with COPD often has increased energy needs due to the work of breathing. Consuming a high-calorie diet helps meet these needs. This can prevent malnutrition and promote optimal energy levels. Limiting fluid intake (B) can lead to dehydration and thicker mucus. Strenuous exercise (C) may exacerbate breathing difficulties. Reducing carbohydrate intake (D) can lead to decreased energy levels.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr. Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride. Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.
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 assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.