Nokea
A nurse is caring for a client who has heart failure. Drag words from the choices below to fill
in each blank in the following sentence. The client is at risk for developing _________ and_________
Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.
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A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
- A. Twist at the waist when standing from a seated position.'
- B. Use a raised toilet seat to maintain your hips above your knees.'
- C. Apply a heating pad to the operative hip to decrease pain.'
- D. Move your stronger leg first when using a walker.'
Correct Answer: B
Rationale: The correct answer is B: Use a raised toilet seat to maintain your hips above your knees. This is important post-total hip arthroplasty to prevent hip dislocation. By keeping the hips above the knees, it reduces stress on the hip joint.
Incorrect choices:
A: Twisting at the waist can strain the hip joint post-surgery.
C: Applying heat can increase inflammation and risk of infection.
D: Moving the stronger leg first can lead to uneven weight distribution, increasing the risk of falls.
A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
- A. Suppressed bronchiolar inflammatory response
- B. Decreased responsiveness of airways to allergens
- C. Acute loss of alveolar elasticity
- D. Inability to exhale retained carbon dioxide
Correct Answer: D
Rationale: The correct answer is D: Inability to exhale retained carbon dioxide. During an acute asthma attack, there is airway obstruction, leading to air trapping and difficulty exhaling. This causes retention of carbon dioxide, leading to respiratory acidosis. This acidosis can further worsen the bronchoconstriction and airway inflammation in asthma. Choices A, B, and C do not directly contribute to the manifestations of an acute asthma attack. Suppressed bronchiolar inflammatory response (A) and decreased responsiveness of airways to allergens (B) would not cause the acute symptoms seen in an asthma attack. Acute loss of alveolar elasticity (C) is not a primary contributing factor to the acute manifestations of asthma.
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication with food to help with absorption.
- B. If my heart starts racing
- C. my provider might need to adjust my dosage.
- D. I should stop taking this medication once my symptoms improve.
- E. I will take this medication at night before bed.
Correct Answer: B
Rationale: Correct Answer: B - If my heart starts racing
Rationale: This statement indicates an understanding of a potential side effect of levothyroxine, which is palpitations or rapid heart rate. It shows that the client is aware of the importance of monitoring for adverse reactions and seeking medical attention if necessary. This is crucial as it can indicate overmedication, which can be harmful.
Incorrect Choices:
A: Taking levothyroxine with food can interfere with its absorption, reducing its effectiveness.
C: Adjusting the dosage is the healthcare provider's responsibility based on lab results, not the client's decision.
D: Stopping the medication abruptly can lead to a worsening of hypothyroidism symptoms.
E: Taking levothyroxine at night can interfere with sleep patterns and absorption.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.'
- B. I rest in my recliner with my feet elevated for about an hour every afternoon.'
- C. I use my heating pad on a low setting to keep my feet warm.'
- D. I soak my feet in hot water before trimming my toenails.'
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease. Choice B may improve circulation, but it does not address foot care directly. Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease. Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (A) may not necessarily prevent wandering. Using chemical restraints (B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (D) may increase agitation and wandering behavior.