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A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I should apply antibiotic ointment to the lesions.'
- B. I should use natural skin condoms during sexual intercourse.'
- C. I should expect my lesions to resolve in 6 weeks.'
- D. I should expect to take my medication for 3 weeks.'
Correct Answer: C
Rationale: The correct answer is C: "I should expect my lesions to resolve in 6 weeks." This indicates effectiveness of teaching because it shows the client understands the natural course of genital herpes and the expected timeline for resolution. Choice A is incorrect because antibiotic ointment is not recommended for herpes. Choice B is incorrect because natural skin condoms do not provide adequate protection against herpes. Choice D is incorrect because treatment duration may vary and is not always 3 weeks.
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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (A) may not necessarily prevent wandering. Using chemical restraints (B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (D) may increase agitation and wandering behavior.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To determine the infusion rate, we first calculate the total volume of the solution to be infused (100 mL) over the total time (1 hr). Therefore, the infusion pump should be set to deliver 100 mL/hr (Choice C). This ensures the correct administration of potassium chloride 10 mEq IV over 1 hr. Choices A, B, and D are incorrect because they do not accurately reflect the infusion rate required for the specified dose and time frame.
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
- A. Check the client's blood pressure every 8 hr.
- B. Assess urine output hourly.
- C. Administer opioids PO.
- D. Monitor for hypokalemia as a manifestation of acute rejection.
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (Choice A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (Choice C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (Choice D) is important but not the priority in the immediate postoperative period.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A because Cushing's triad consists of hypertension, bradycardia, and irregular respirations. In a client with a traumatic brain injury, increased intracranial pressure can lead to Cushing's triad due to brainstem compression. Option A reflects an increase in blood pressure, which is a key component of Cushing's triad. Choices B, C, and D do not align with the expected findings of Cushing's triad. Choice B indicates a decrease in heart rate, which is contrary to the bradycardia seen in Cushing's triad. Choice C mentions rapid respirations, whereas irregular or shallow respirations are more characteristic. Choice E mentions hypotension, which is not part of Cushing's triad. Therefore, option A is the correct choice as it aligns with the manifestation of hypertension in Cushing's triad.