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A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Frothy sputum.
- B. Dependent edema.
- C. Jugular distention.
- D. Nocturnal polyuria.
Correct Answer: A
Rationale: Frothy sputum is a symptom of left-sided heart failure due to pulmonary congestion and edema.
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A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?
- A. Plan to have potassium blood levels checked when taking thiazide diuretics.
- B. Limit alcohol consumption to 3 drinks a day when hypertensive.
- C. Set your goal body weight within 25% of ideal body weight.
- D. Plan to lower sodium intake to 3,000 mg each day.
Correct Answer: A
Rationale: Monitoring potassium levels is essential with thiazide diuretics, which can cause hypokalemia, ensuring safe management of hypertension.
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?
- A. Review stress factors that can cause disease exacerbation.
- B. Evaluate fluid and electrolyte levels.
- C. Promote physical mobility.
- D. Provide emotional support.
Correct Answer: B
Rationale: Evaluating fluid and electrolyte levels is the priority due to significant fluid loss and electrolyte imbalances during an acute exacerbation of ulcerative colitis.
A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Use several different scales to obtain the weight.
- B. Weigh at the same time each day.
- C. Calibrate weight scales every week.
- D. Measure weight just prior to voiding.
Correct Answer: B
Rationale: Weighing at the same time each day ensures consistent measurements, critical for monitoring fluid retention in CKD.
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
- A. Abduction.
- B. Internal rotation.
- C. External rotation.
- D. Adduction.
Correct Answer: A
Rationale: Abduction prevents hip dislocation by keeping the leg away from the midline, maintaining joint stability post-arthroplasty.
A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.