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During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct Answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.
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A healthcare professional is preparing to administer multiple medications to a client with dysphagia. What action should the healthcare professional take?
- A. Offer the medications with a full glass of water
- B. Crush the medications and mix them together
- C. Provide the medications through a straw
- D. Mix the medications with applesauce
Correct Answer: C
Rationale: Clients with dysphagia have difficulty swallowing, so providing medications through a straw can help control the flow and prevent aspiration. Offering medications with a full glass of water (Choice A) may increase the risk of aspiration. Crushing medications and mixing them together (Choice B) can alter the medication's effectiveness or cause adverse effects. Mixing medications with applesauce (Choice D) may also present a choking hazard for clients with dysphagia.
A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?
- A. Flush the NG tube with 60 mL of water
- B. Verify tube placement
- C. Crush the medications and dissolve them in water
- D. Administer all medications together
Correct Answer: B
Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.
A client with chronic obstructive pulmonary disease (COPD) is being taught breathing exercises by a nurse. What instruction should the nurse include to improve oxygenation?
- A. Use pursed-lip breathing during activities
- B. Use deep breathing exercises after meals
- C. Perform diaphragmatic breathing during exercise
- D. Breathe in short, shallow breaths
Correct Answer: A
Rationale: The correct instruction the nurse should include to improve oxygenation for a client with COPD is to 'Use pursed-lip breathing during activities.' Pursed-lip breathing helps improve oxygenation by slowing down the respiratory rate, reducing the work of breathing, and keeping the airways open. This technique also helps prevent the collapse of small airways during exhalation, allowing for more complete emptying of the lungs. Choices B, C, and D are incorrect because deep breathing exercises after meals, diaphragmatic breathing during exercise, and breathing in short, shallow breaths do not specifically target the improvement of oxygenation in individuals with COPD.
A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased white blood cell count
- C. Increased hematocrit
- D. Decreased white blood cell count
Correct Answer: C
Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.
A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct Answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.