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A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Take naproxen for generalized discomfort
- B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
- C. Take diuretics early in the morning and before bedtime
- D. Exercise at least three times per week
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. This is crucial in heart failure management as sudden weight gain can indicate fluid retention, worsening heart failure, and the need for medication adjustment. Option A is incorrect as naproxen can worsen heart failure symptoms. Option C is incorrect as diuretics should be taken in the morning to prevent nighttime urination. Option D is incorrect as the frequency and intensity of exercise should be tailored based on the individual's condition.
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A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
- A. Inspect the abdomen for skin integrity.
- B. Ask the client about having a history of abdominal pain.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen in each of the four quadrants.
- E. Palpate the abdomen gently for tenderness.
Correct Answer: A,B,C,D,E
Rationale: Action to Take: A, B; Potential Condition: None; Parameter to Monitor: C, E.
Rationale:
1. Inspecting for skin integrity (A) allows the nurse to assess for any visible abnormalities or lesions.
2. Asking about abdominal pain history (B) provides insight into potential underlying conditions.
3. Auscultating for bowel sounds (C) helps assess gastrointestinal motility and function.
4. Percussing the abdomen (D) helps identify areas of abnormal fluid or gas accumulation.
5. Palpating for tenderness (E) assesses for pain or masses in the abdomen.
Summary:
- Not inspecting the abdomen (A) could miss skin abnormalities.
- Not asking about abdominal pain history (B) could overlook important medical information.
- Skipping auscultation (C) could lead to missing crucial gastrointestinal assessment.
- Not percussing (D) may result in overlooking potential abdominal issues.
- Omitting palpation (E) could miss detecting tend
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Generalized urticaria.
- B. Distended jugular veins.
- C. Blood pressure 184/92 mm Hg.
- D. Bilateral flank pain.
Correct Answer: A
Rationale: The correct answer is A: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. The release of histamine during the reaction causes itching and skin rash. Distended jugular veins (B) are more indicative of fluid overload or heart failure. Blood pressure of 184/92 mm Hg (C) is elevated but not specific to an allergic reaction. Bilateral flank pain (D) may suggest kidney issues or musculoskeletal problems, not necessarily related to an allergic reaction.