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A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?
- A. Peripheral edema
- B. Jugular vein distention
- C. Hepatomegaly
- D. Crackles in the lungs
Correct Answer: D
Rationale: The correct answer is D: Crackles in the lungs. Left-sided heart failure leads to fluid accumulation in the lungs, causing crackles on auscultation. This indicates pulmonary congestion. Peripheral edema (A) is more common in right-sided heart failure. Jugular vein distention (B) is typically seen in right-sided heart failure due to increased venous pressure. Hepatomegaly (C) is more common in conditions like liver disease, not specifically left-sided heart failure.
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Identify measures that the nurse should use to reduce health care disparities
- A. Use cultural competency guidelines
- B. Use a family member as the interpreter
- C. Use standardized evidence-based care guidelines
- D. Complete the health history as rapidly as possible
Correct Answer: A
Rationale: Using cultural competency guidelines, standardized evidence-based care, and incorporating racial/cultural differences in care plans helps mitigate disparities. Rushing the process or relying solely on family interpreters can worsen outcomes.
The nurse is teaching a client who has a hip prostheses following total hip replacement. Which of the following should be included in the instructions for home care?
- A. Avoid climbing stairs for 3 months.
- B. Ambulate using crutches only.
- C. Sleep only on your back.
- D. Do not cross legs.
Correct Answer: D
Rationale: Crossing legs can dislocate the hip prosthesis.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.
Which factors place a client at risk for serotonin syndrome?
- A. Coprescription of antidepressants from different classes such as MAOIs and SSRIs
- B. Abnormal levels of cortisol in the body
- C. Adequate time between weaning from one antidepressant drug to initiating another
- D. Premenstrual syndrome
Correct Answer: A
Rationale: Combining certain classes of antidepressants increases serotonin levels excessively, leading to serotonin syndrome.
A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?
- A. All staff nurses are required to participate in quality improvement projects.
- B. Even as a new nurse, you can implement activities designed to improve care.
- C. It's easy to identify which indicators should be used to measure quality improvement.
- D. You should ask to be assigned to the research and quality committee.
Correct Answer: B
Rationale: The correct answer is B because even as a new nurse, one can contribute to improving care by implementing activities. This response encourages the new nurse to actively engage in the quality improvement process, fostering a sense of ownership and commitment to enhancing patient outcomes. Choice A is incorrect as participation in QI projects is not solely based on tenure. Choice C is incorrect as identifying indicators requires knowledge and experience. Choice D is incorrect as it suggests a specific assignment rather than empowering the new nurse to take initiative in improving care.