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A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
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A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
- A. Encourage the client to unseat every 2 hr
- B. Apply a cold compress to the suprapubic area
- C. Secure the urinary catheter to the upper left quadrant of the clients abdomen
- D. Use 0.9% sodium chloride to perform an intermittent bladder irrigation
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?
- B. After this procedure
- C. you will feel much better.
- D. Tell me why you are scared to have this procedure.
Correct Answer: D
Rationale: Rationale: The correct response is D because it demonstrates active listening and empathy by encouraging the client to express their fears. By asking the client to elaborate on their fears, the nurse can address specific concerns and provide appropriate support. This promotes trust and open communication between the nurse and client, leading to better outcomes.
Incorrect Responses:
A: This response assumes the fear is related to needles and does not address the client's specific concerns about the procedure.
B: This response is incomplete and does not acknowledge the client's fear.
C: This response minimizes the client's feelings and does not address the underlying fear.
Overall, these responses fail to address the client's emotional needs and may not effectively alleviate their fear or anxiety.
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to the loss of protein in the urine, specifically albumin. Hyperalbuminemia (choice A) is incorrect as albumin is lost in the urine. Decreased serum lipid levels (choice C) are incorrect because nephrotic syndrome is associated with hyperlipidemia due to altered lipid metabolism. Decreased coagulation (choice D) is incorrect as nephrotic syndrome is actually associated with a hypercoagulable state due to loss of anticoagulant proteins in the urine.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.