Nokea
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: C
Rationale: The correct answer is C: Confusion. In left-sided heart failure, decreased cardiac output can lead to decreased perfusion to the brain, resulting in confusion. Weight gain (A) is more indicative of fluid retention, distended abdomen (B) is a sign of ascites or abdominal organ enlargement, and dyspnea (D) is a common symptom of heart failure but not a direct indicator of decreased cardiac output.
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A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Butterfly' rash
- C. Esophagitis
- D. Trophil
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus (SLE) commonly presents with joint inflammation due to inflammation of the synovial membrane. This can lead to pain, swelling, and stiffness in the joints. The other choices are incorrect because: B: Butterfly rash is a characteristic facial rash seen in SLE, but it is not related to joint involvement. C: Esophagitis is inflammation of the esophagus and is not a common manifestation of SLE. D: Trophil is not a recognized term in relation to SLE or its symptoms.
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, you will feel much better.'
- C. Tell me why you are scared to have this procedure.'
- D. Let's discuss your concerns about this procedure.'
Correct Answer: D
Rationale: Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
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, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood, instead of a friend.'
- B. This surgery has minimal blood loss, so you will not require a transfusion.'
- C. You can donate your own blood a few weeks prior to this surgery.'
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.'
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the best option because it addresses the client's concern about needing a blood transfusion during surgery by suggesting an effective proactive measure. Donating your own blood before surgery, known as autologous donation, ensures that you have your own blood available if needed, reducing the risk of transfusion reactions and complications. It allows for a personalized and safe option in case of blood loss during the procedure.
As for the other options:
A: This statement does not provide relevant information about blood transfusions.
B: This statement is inaccurate as total hip arthroplasty can result in significant blood loss requiring a transfusion.
D: While using screened donor blood reduces the risk of infusion reactions, it does not address the client's specific concern about needing a transfusion during surgery.
Therefore, option C is the most appropriate response as it directly addresses the client's query and offers a practical solution.
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 36.3° C (90.9° F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A. Capillary refill time of 6 seconds in the toe indicates poor circulation, which is a concerning finding post-surgery with an external fixator. Immediate intervention is needed to prevent complications like tissue ischemia. Choices B, C, and D do not require immediate intervention as they are within normal limits postoperatively. Blood in the drain is expected, the temperature is normal, and pain level 7 is manageable with appropriate pain management.