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A nurse is assessing a male adolescent client who has heart failure. Based on the client's chart, which of the following actions should the nurse plan to take?
- A. Withhold spironolactone
- B. Administer ferrous sulfate
- C. Administer furosemide
- D. Withhold digoxin
Correct Answer: C
Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.
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A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel (AP)?
- A. Client who has chronic obstructive pulmonary disease and needs guidance with incentive spirometry
- B. Client who has awoken following a bronchoscopy and requests a drink
- C. Client who had a myocardial infarction 3 days ago and reports chest discomfort
- D. Client who had a cerebrovascular accident 2 days ago and needs help toileting
Correct Answer: D
Rationale: The correct answer is D because the client who had a cerebrovascular accident 2 days ago and needs help toileting is stable and the task is appropriate for delegation to an assistive personnel (AP). Choices A, B, and C involve clients with more complex care needs that require the expertise of a nurse. Choice A involves providing guidance with incentive spirometry, which requires specialized knowledge and assessment skills. Choice B involves a client who has just undergone a bronchoscopy, so close monitoring is essential to assess for any complications. Choice C involves a client who had a myocardial infarction 3 days ago and is reporting chest discomfort, which could indicate a potential cardiac issue requiring immediate nursing assessment and intervention.
A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct Answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct Answer: A
Rationale: The correct answer is A: Paradoxical pulse. Paradoxical pulse, which is a significant drop in systolic blood pressure during inspiration, indicates cardiac tamponade, a life-threatening complication of pericarditis. This finding requires immediate attention as it suggests potential compromised cardiac function. Choices B, C, and D are associated with pericarditis but do not indicate the same level of urgency as paradoxical pulse.
A healthcare provider is assessing a client for allergies before administering propofol. Which of the following allergies is a contraindication to the medication?
- A. Eggs
- B. Milk
- C. Shrimp
- D. Peanuts
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct Answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.