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A nurse is caring for a patient who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider? Which finding post-bowel resection should the nurse report?
- A. Soft, formed stools
- B. Abdominal distension
- C. Mild incisional pain
- D. Nausea
Correct Answer: B
Rationale: The correct answer is B: Abdominal distension. This finding could indicate a possible complication such as bowel obstruction or ileus post-bowel resection. The nurse should report this symptom promptly to the provider for further evaluation and intervention to prevent potential complications. Soft, formed stools (A) are expected after bowel resection, indicating bowel function is returning. Mild incisional pain (C) is common postoperatively and can be managed with pain medication. Nausea (D) can also be common after surgery but may require monitoring if persistent or severe. There are no additional choices provided, but it is essential for the nurse to prioritize reporting any unusual or concerning findings to ensure the patient's safety and well-being.
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A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect? What finding should the nurse expect in left-sided heart failure?
- A. Frothy sputum
- B. Dependent edema
- C. Nocturnal polyuria
- D. Jugular distention
Correct Answer: A
Rationale: The correct answer is A: Frothy sputum. In left-sided heart failure, the failing left ventricle results in blood backing up into the lungs causing pulmonary congestion. This leads to the production of frothy, pink-tinged sputum due to blood-tinged fluid leaking into the alveoli. Dependent edema (choice B) is more indicative of right-sided heart failure. Nocturnal polyuria (choice C) is not a typical finding in left-sided heart failure. Jugular distention (choice D) is more commonly seen in right-sided heart failure due to increased venous pressure.
A nurse assumes various roles while working with patients. Which of the following describes the nursing role of protecting the patient and supporting the patient's decisions? Which role involves protecting and supporting patient decisions?
- A. Advocate
- B. Manager
- C. Caregiver
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Advocate. Nurses act as advocates by protecting the patient's rights, ensuring their voice is heard, and supporting their decisions. Advocacy involves standing up for the patient's best interests and promoting autonomy. The other choices are incorrect because: B: Manager focuses on organizing and coordinating care, C: Caregiver involves providing direct physical and emotional care, and D: Educator focuses on providing information and teaching. Advocacy uniquely encompasses protecting and supporting the patient's decisions, making it the most appropriate choice in this scenario.
A nurse is educating a parent of a 6-month-old infant about car seat safety. Which statement from the parent indicates a correct understanding of the teaching?,Which statement indicates correct understanding of car seat safety?
- A. Our car seat is an infant model and is anchored in the car.
- B. The car seat is rear-facing in the front passenger seat.
- C. I can fit my hand between the baby and the car seat harness.
- D. Our car seat is front-facing in the back seat.
Correct Answer: A
Rationale: The correct answer is A because anchoring the infant car seat in the car is crucial for safety. This ensures the seat is securely installed and minimizes the risk of injury during a collision. Choice B is incorrect as rear-facing car seats should never be placed in the front passenger seat due to the presence of airbags, which can be dangerous for infants. Choice C is incorrect because the harness should be snug against the infant's body without any slack, and being able to fit a hand between the harness and the baby indicates it is too loose. Choice D is incorrect as infants should be in rear-facing seats until at least 2 years old for optimal safety.
A nurse is caring for a patient who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse monitor? Which lab test should the nurse monitor for heparin?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). aPTT is the most appropriate lab test to monitor for patients receiving heparin therapy because it reflects the drug's anticoagulant effect. Heparin works by inhibiting thrombin and factor Xa, which can be measured effectively by monitoring aPTT levels. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for potential heparin-induced thrombocytopenia, but aPTT is more directly related to heparin's anticoagulant effect.
A nurse is providing teaching to a patient who has a new prescription for levothyroxine. Which of the following instructions should the nurse include? What instructions should the nurse include for levothyroxine?
- A. Take the medication with a meal.
- B. Take the medication in the morning on an empty stomach.
- C. Take the medication at bedtime.
- D. Take the medication with grapefruit juice.
Correct Answer: B
Rationale: The correct answer is B: Take the medication in the morning on an empty stomach. Levothyroxine is best absorbed when taken on an empty stomach, preferably 30 minutes to 1 hour before breakfast. This ensures optimal absorption and effectiveness of the medication. Taking it with a meal (choice A) may interfere with absorption due to food interactions. Taking it at bedtime (choice C) may lead to insomnia or disrupted sleep patterns. Taking it with grapefruit juice (choice D) is not recommended, as grapefruit juice can interfere with the absorption of certain medications. Thus, the most appropriate instruction for the patient is to take levothyroxine in the morning on an empty stomach for optimal efficacy.