Nokea
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
- A. Oliguria.
- B. Bradycardia.
- C. Elevated blood pressure.
- D. Fever.
Correct Answer: A
Rationale: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
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When planning to move a person with a possible spinal cord injury, the nurse should direct the team to:
- A. Limit movement of the arms by wrapping them next to the body.
- B. Move the person gently to help reduce pain.
- C. Immobilize the head and neck to prevent further injury.
- D. Cushion the back with pillows to ensure comfort.
Correct Answer: C
Rationale: Immobilizing the head and neck prevents exacerbation of a spinal cord injury during movement.
A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
- A. Providing passive range of motion exercises to the left extremities during the bed bath.
- B. Elevating the foot of the bed to reduce edema.
- C. Pulling up the client under the left shoulder when getting out of bed to a chair.
- D. Putting high top tennis shoes on the client after bathing.
Correct Answer: C
Rationale: Pulling under the paralyzed shoulder can cause injury or discomfort. Passive ROM, elevating the bed, and high-top shoes are appropriate for paralysis care.
A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?
- A. Zyban (Bupropion)
- B. Nicotine (Nicotrol)
- C. Nitroglycerin (Tridil)
- D. Ibuprofen (Advil)
Correct Answer: A
Rationale: Zyban (bupropion) is an antidepressant that reduces nicotine cravings and withdrawal symptoms, making it effective for smoking cessation in Buerger's disease. Nicotine replacement (Nicotrol) may help but continues nicotine exposure, nitroglycerin is for angina, and ibuprofen is irrelevant.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will:
- A. Avoid exercise
- B. Lose weight
- C. Perform leg lifts every 4 hours
- D. Wear support hose, using rubber bands to hold the stockings up
Correct Answer: B
Rationale: Weight loss reduces pressure on veins and improves circulation, critical for managing DVT and thrombophlebitis in an obese client. Avoiding exercise increases stasis, leg lifts are insufficient alone, and rubber bands can cause constriction, negating support hose benefits.