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During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?
- A. S3 ventricular gallop
- B. Apical click
- C. Systolic murmur
- D. Split S2
Correct Answer: A
Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.
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When introducing solid foods to an infant, what food should be recommended to be introduced first?
- A. Strained fruits
- B. Pureed meats
- C. Cooked egg whites
- D. Iron-fortified cereal
Correct Answer: D
Rationale: When introducing solid foods to infants, iron-fortified cereal is usually recommended as the first food due to its high nutritional value and the importance of iron for the baby's development. Strained fruits (choice A) are often introduced later due to their higher sugar content. Pureed meats (choice B) and cooked egg whites (choice C) are usually introduced after iron-fortified cereal to provide additional sources of protein and other nutrients.
A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?
- A. Eating one medium apple is a good snack option.
- B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
- C. Choosing a ½ cup of bran cereal for breakfast is ideal.
- D. Opting for 1 ounce of almonds when hungry midday is recommended.
Correct Answer: C
Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.
After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.
Which information is a priority for the client to reinforce after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours as the preparation and test are tiring.
- C. During waking hours, drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure urine output for the next day and immediately notify the healthcare provider if it decreases.
Correct Answer: D
Rationale: After intravenous pyelography, monitoring urine output is crucial to assess kidney function and detect any early signs of complications. Decreased urine output could indicate a problem with kidney function or potential complications from the procedure. While rest and hydration are important, the priority lies in monitoring urine output for any abnormalities. Eating a light diet may be recommended, but it is not the priority post-procedure instruction.
A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.