Nokea
How should fluid overload in a patient with heart failure be managed?
- A. Administer diuretics
- B. Increase fluid intake
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.
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When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?
- A. Expel any air bubbles at the top of the prefilled syringe
- B. Massage the injection site to evenly distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct Answer: C
Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.
A nurse is reviewing the results of an arterial blood gas analysis of a client who has chronic obstructive pulmonary disease. Which of the following results should the nurse expect?
- A. PaO2 of 95 mm Hg
- B. PaCO2 of 55 mm Hg
- C. HCO3 of 24 mEq/L
- D. pH level of 7.35
Correct Answer: B
Rationale: In chronic obstructive pulmonary disease, there is impaired gas exchange, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. A PaCO2 of 55 mm Hg is higher than the normal range (35-45 mm Hg) and is indicative of respiratory acidosis in COPD. Choices A, C, and D are not typically associated with COPD. PaO2 may be decreased, HCO3 may be elevated to compensate for acidosis, and pH may be lower than 7.35 due to respiratory acidosis in COPD.
A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?
- A. Massage the affected extremity every 4 hours.
- B. Encourage the client to remain on bed rest.
- C. Apply cold packs to the affected extremity.
- D. Encourage the client to ambulate frequently.
Correct Answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Weight gain
- C. Hypertension
- D. Decreased deep tendon reflexes
Correct Answer: D
Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.
A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?
- A. Stoma that is red and moist
- B. Purulent drainage from the stoma
- C. Stoma that is dry and purple
- D. Mild swelling around the stoma
Correct Answer: C
Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.