Nokea
An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Assist with ambulation in the hallway
- B. Encourage active range of motion exercises
- C. Provide a bedside commode for toileting
- D. Teach to sleep in a side-laying position
Correct Answer: C
Rationale: Providing a bedside commode reduces the need for the client to walk to the bathroom, decreasing strain on the heart.
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The main risk factor for developing deep vein thrombosis is:
- A. Prolonged immobility
- B. Age
- C. Obesity
- D. Family history
Correct Answer: A
Rationale: Prolonged immobility, such as during long flights or post-surgery, is a significant risk factor for developing deep vein thrombosis (DVT).
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
- A. Urinary output less than intake
- B. Bruising at the insertion site
- C. Slurred speech and confusion
- D. Discomfort in the left leg
Correct Answer: C
Rationale: Slurred speech and confusion may indicate a neurological complication, such as a stroke, which requires immediate intervention.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
Aspirin has been ordered for the child with rheumatic fever (RF) in order to:
- A. Keep the patent ductus arteriosus (PDA) open
- B. Reduce joint inflammation
- C. Decrease swelling of strawberry tongue
- D. Treat ventricular hypertrophy of endocarditis
Correct Answer: B
Rationale: Aspirin helps alleviate the joint inflammation and pain experienced in RF.
The following contribute to the natural immunity transmitted in breast milk:
- A. Macrophages
- B. Natural killer cells
- C. Lysozyme
- D. Secretory IgA
Correct Answer: D
Rationale: Secretory IgA in breast milk plays a crucial role in providing passive immunity to the infant by protecting mucosal surfaces from pathogens.