Nokea
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for which of the following signs of fluid overload?
- A. Weight loss and increased appetite.
- B. Increased urine output and dehydration.
- C. Swelling in the legs and shortness of breath.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.
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What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
- A. Who will provide client care
- B. Privacy of information
- C. How insurance information is obtained
- D. Where a chart can be stored
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
What should the nurse do first when caring for a client with a suspected spinal cord injury?
- A. Immobilize the spine
- B. Place the client in a supine position
- C. Administer analgesics
- D. Assess the airway
Correct Answer: A
Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.
What is the most important intervention for a client with acute myocardial infarction (MI)?
- A. Administer aspirin
- B. Administer oxygen
- C. Administer morphine
- D. Administer nitroglycerin
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.
Which factors increase the risk of sexually transmitted diseases (STDs)?
- A. alcohol use
- B. certain types of sexual practices
- C. oral contraception use
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D: all of the above. Alcohol use can impair judgment leading to risky sexual behaviors. Certain sexual practices like unprotected sex or having multiple partners increase STD risk. Oral contraception does not protect against STDs. Therefore, all factors (A, B, C) collectively increase the risk of STDs.