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A nurse is caring for a client who has a new diagnosis of heart failure. Which of the following findings should the nurse expect?
- A. Orthopnea
- B. Bradycardia
- C. Weight loss
- D. Hypotension
Correct Answer: A
Rationale: Orthopnea, difficulty breathing when lying flat, is common in heart failure due to fluid accumulation in the lungs.
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A nurse is reinforcing teaching with a client who has a new prescription for a budesonide inhaler. Which of the following instructions should the nurse include?
- A. Rinse your mouth after use.
- B. Use it as needed for shortness of breath.
- C. Take it twice daily.
- D. Shake the inhaler before use.
Correct Answer: A
Rationale: Rinsing the mouth after using a budesonide inhaler prevents oral thrush, a common side effect of inhaled corticosteroids.
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
A nurse is reinforcing teaching with a client who is scheduled for an exercise stress test. Which of the following instructions should the nurse include?
- A. Eat a large meal before the test.
- B. Wear comfortable shoes.
- C. Take a sedative before the test.
- D. Avoid drinking water during the test.
Correct Answer: B
Rationale: Wearing comfortable shoes ensures safety and ease during the physical activity required for an exercise stress test.
A nurse is caring for a client who has a new diagnosis of trigeminal neuralgia. Which of the following findings should the nurse expect?
- A. Facial pain
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Facial pain, often severe and shock-like, is a hallmark symptom of trigeminal neuralgia affecting the trigeminal nerve.
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include?
- A. Wear deodorant on the day of the procedure.
- B. Avoid caffeine for 24 hours before the procedure.
- C. Schedule the procedure during your menstrual period.
- D. Do not wear jewelry during the procedure.
Correct Answer: D
Rationale: Not wearing jewelry during a mammogram prevents interference with the imaging and ensures accurate results.