Nokea
The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?
- A. Have you had a sore throat in the last month?'
- B. Did you have rheumatic fever as a child?'
- C. Do you have a family history of carditis?'
- D. What over-the-counter (OTC) medications do you take?'
Correct Answer: B
Rationale: Rheumatic fever (B) is a major cause of carditis, especially in children, making it the most relevant question. Sore throat (A) is less specific, family history (C) is rare, and OTC meds (D) are unrelated.
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The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients?
- A. Perform a 'down and dirty' assessment on each client soon after receiving report.
- B. Determine which client should have a bath and inform the unlicensed assistive personnel.
- C. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste.
- D. Pick up any paper on the floor and get the room ready for morning physician rounds.
Correct Answer: A
Rationale: A quick 'down and dirty' assessment (A) prioritizes client stability post-report. Bathing (B), hygiene (C), and room prep (D) are secondary to safety.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.
- A. Encourage a low-fat, low-cholesterol diet.
- B. Instruct the client to walk 30 minutes a day.
- C. Decrease the salt intake to two (2) g a day.
- D. Refer to a counselor for stress reduction techniques.
- E. Teach the client to increase fiber in the diet.
Correct Answer: A,B,D,E
Rationale: Low-fat/cholesterol diet (A), walking (B), stress reduction (D), and high-fiber diet (E) reduce CAD risk. Salt restriction (C) is more specific to CHF or hypertension.
The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's blood pressure and apical rate every four (4) hours.
- B. Place the client on intake and output every shift.
- C. Require the client to sleep with the head of the bed elevated.
- D. Teach the patient to perform Buerger Allen exercises daily.
- E. Determine if the client is on an antiplatelet or anticoagulant medication.
- F. Assess the client's neurological status every shift and prn.
Correct Answer: A,E,F
Rationale: Monitoring BP/apical rate (A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (B) is for fluid status, HOB elevation (C) is for CHF, and Buerger Allen (D) is for PAD.