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A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
- A. Administering diuretics as prescribed.
- B. Encouraging increased fluid intake.
- C. Restricting sodium intake.
- D. Administering pain medications as needed.
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
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A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose regularly.
- B. I can stop taking my insulin when my blood glucose is normal.
- C. I should only use my insulin when I feel symptoms of high blood sugar.
- D. I will eat sugary foods if I feel tired or weak.
Correct Answer: A
Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle.
Incorrect choices:
B: Stopping insulin when blood glucose is normal can lead to dangerous complications.
C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach.
D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control.
In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.
The nurse is taking a patient's family history. Important diseases or problems to ask the patient about include:
- A. emphysema.
- B. head trauma.
- C. mental health issues.
- D. fractured bones.
Correct Answer: C
Rationale: The correct answer is C: mental health issues. When taking a family history, mental health issues are important as they can have a genetic component and can impact the patient's overall health. Emphysema (A) is a respiratory condition, head trauma (B) is not typically hereditary, and fractured bones (D) are usually due to accidents or osteoporosis, not genetic.
Critical thinking in the expert nurse is greatly enhanced by opportunities to:
- A. apply theory in real situations.
- B. work with physicians to provide patient care.
- C. follow physician orders in providing patient care.
- D. develop nursing diagnoses for commonly occurring illnesses.
Correct Answer: A
Rationale: The correct answer is A because applying theory in real situations allows nurses to analyze, evaluate, and problem-solve effectively. This promotes critical thinking by integrating knowledge into practice. Working with physicians (B) and following orders (C) do not directly enhance critical thinking as they focus more on collaboration and task completion. Developing nursing diagnoses (D) is important but does not specifically target critical thinking skills like applying theory does.
A nurse is caring for a patient who has undergone a colonoscopy. The nurse should prioritize monitoring for which of the following complications?
- A. Hypotension.
- B. Bleeding or perforation.
- C. Constipation.
- D. Pain at the insertion site.
Correct Answer: B
Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
- A. Palpate over the area to identify increased pain and tenderness.
- B. Ask the child to take shallow breaths, and percuss over the area again.
- C. Refer the child immediately because of suspicion of an increased amount of air in the lungs.
- D. Consider this a normal finding for a child this age, and proceed with the examination.
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.