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Complete the following sentence/sentences by choosing from the list/lists of options. The nurse should recognize that the client is most likely experiencing--------------as evidenced by------------------
- A. High BMI
- B. Obstructive sleep apnea
- C. A heart failure exacerbation
- D. A chronic obstructive pulmonary disease exacerbation
- E. Orthopnea
- F. History of smoking
Correct Answer: C,E
Rationale: The nurse should recognize that the client is most likely experiencing a heart failure (HF) exacerbation, as evidenced by
orthopnea. Orthopnea (ie, labored breathing in the supine position), decreased capillary oxygen saturation, extra heart tones
(eg, S3), bilateral lower extremity edema, >5 lb [2.3 kg] weight gain in 1 week, and adventitious lung sounds (eg, crackles)
indicate fluid overload
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The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?
- A. My child will eat but only if I cook the same meal every day.
- B. My child will make only brief periods of eye contact with the teacher.
- C. My child will occasionally play with other children at the park.
- D. My child will squeeze a soft toy instead of banging the head.
Correct Answer: A
Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy
The nurse is reinforcing home care teaching to the client. Which statement by the client requires the nurse to provide further instruction?
- A. I should ask family members to bring prepared meals to me." (13%)
- B. "I should eat small, frequent meals every 2-3 hours." (16%)
- C. I will avoid drinking fluids with my meals." (30%)
- D. I will eat hot soups to settle my stomach." (38%)
Correct Answer: D
Rationale: Self-management of hyperemesis gravidarum is an important component of discharge teaching. The goal of home care is to prevent nausea
and vomiting and promote appropriate nutritional intake and weight gain, which can support a healthy pregnancy.
Some triggers for nausea and vomiting include an empty or overly full stomach, strong food odors, and greasy or fatty foods. It is often
recommended that clients eat cold or bland foods due to the increased aromas associated with hot foods. Therefore, the nurse should
provide further teaching to this client who plans to eat hot soup because this may precipitate nausea (Option 4). The nurse can suggest
eating foods such as toast, crackers, nuts, or cold cereal.
Which of the following findings indicate that the client is improving as expected? Select all that apply.
- A. Blood pressure 138/70 mm Hg
- B. Clear lung sounds
- C. Increased urinary output
- D. SpO, 95% on room air
- E. Unilateral lower extremity edema
Correct Answer: A,B,C,D
Rationale: Clinical improvement in a client with heart failure includes manifestations of reduced cardiac workload and improved fluid
volume status and gas exchange. A decrease in blood pressure from 170/100 mm Hg to 138/70 mm Hg and increased
urinary output indicate effectiveness of diuretics to reduce circulatory fluid volume and antihypertensive medications to
decrease cardiac workload . In addition, clear lung sounds and an increased capillary oxygen
saturation (SpO2) indicate a decrease in pulmonary congestion and an improvement in fluid volume status
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.
- A. Hyperkalemia
- B. Dysrhythmias
- C. Elevated BUN
- D. Seizures
- E. Hyponatremia
- F. Acute kidney injury
Correct Answer: A,B
Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.
The nurse reinforces discharge teaching to the client after laser peripheral iridotomy. Which of the following client statements indicate an understanding of the teaching? Select all that apply.
- A. Gently pulling down my lower eyelid creates a pocket where I should administer the drops.
- B. I will apply pressure over the inner corner of my eye after administering each medication
- C. I will stop taking diphenhydramine because it can cause a glaucoma attack.
- D. I will wait 5 minutes between administering each eye drop medication.
- E. Touching my eye with the medication applicator may cause an infection.
Correct Answer: A,B,C,D,E
Rationale: Laser peripheral iridotomy is a surgical intervention for acute angle-closure glaucoma (ACG) that involves creating a small hole in the iris to
prevent the drainage pathway from closing and improve movement of aqueous humor into regular outflow channels. Ophthalmic alpha-
adrenergic agonists (eg, apraclonidine, brimonidine) are administered postoperatively to reduce aqueous humor production and prevent an
elevation in intraocular pressure.
Important considerations for the administration of ophthalmic drops include:
• Pulling the lower eyelid down by gently pressing on the lower orbital bone to expose the conjunctival sac (Option 1)
• Applying pressure over the inner corner of the eye (eg, lacrimal duct) after each medication to avoid systemic absorption (Option 2)
• Waiting at least 5 minutes before instilling a different medication into the same eye to allow absorption of the first medication and to
avoid overflow with multiple drops (Option 4)
• Holding the dropper ½*% in (1-2 cm) above the conjunctival sac to prevent contamination of the dropper and infection of the eye
(Option 5)
Clients should also be instructed to consult with their health care provider before taking over-the-counter medications (eg, decongestants,
anticholinergics, antihistamines) because a subsequent episode of acute ACG may be triggered by certain medications (Option 3).