Nokea
The client underwent a colon surgery yesterday, and just started ice chips today, Which of the following is an expected assessment finding?
- A. Hypoactive bowel sounds
- B. Absence of bowel sounds
- C. Hyperactive bowel sounds in the upper quadrants and hypoactive bowel sounds in the lower quadrant
- D. Hyperactive bowel sounds
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a client with a history of congestive heart failure. The client's dyspnea has worsened over the past 2 hours. The nurse should:
- A. Increase the oxygen flow rate to 6L per minute
- B. Place the client in high Fowler's position
- C. Administer Lasix (furosemide) immediately
- D. Encourage the client to cough and deep breathe
Correct Answer: B
Rationale: Placing the client in high Fowler's position eases dyspnea in worsening congestive heart failure by reducing preload oxygen adjustment needs orders, Lasix requires confirmation, and coughing won't help acute fluid overload. Nurses prioritize positioning, monitoring respiratory status, aiding comfort in this cardiac emergency.
A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?
- A. Hypotension
- B. Bradycardia
- C. Crackles in the lungs
- D. Dry mucous membranes
Correct Answer: C
Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients.
A client has a new prescription for a metered-dose inhaler (MDI). Which of the following statements indicates an understanding of the teaching?
- A. I will shake the inhaler before use.
- B. I will breathe out forcefully after inhaling the medication.
- C. I will take the medication with food.
- D. I will use a spacer with the inhaler.
Correct Answer: A
Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication inside the inhaler. This action helps to disperse the medication evenly, allowing for consistent dosing during inhalation. Breathing out forcefully, taking the medication with food, and using a spacer are not related to the correct use of a metered-dose inhaler and may not lead to optimal medication delivery.
A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?
- A. The client uses a walker to move from the bed to the chair.
- B. The client has a strong cough.
- C. The client can bear weight on both legs.
- D. The client has a normal respiratory rate.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?
- A. Screening for early detection
- B. Teaching about adhering to a low-sodium diet
- C. Promoting health before diagnosis
- D. Detecting disease early
Correct Answer: B
Rationale: Tertiary prevention occurs post-diagnosis, aiming to reduce disability and optimize function, as with this heart failure client. Teaching about a low-sodium diet helps manage symptoms reducing fluid retention, easing heart strain preventing readmissions by enhancing self-care after treatment. Screening or early detection aligns with secondary prevention, identifying issues before symptoms escalate. Promoting health pre-diagnosis is primary prevention, averting illness onset. Here, the nurse targets rehabilitation, addressing an established condition to minimize complications like edema, common in heart failure's chronic cycle. This education empowers the client, aligning with tertiary care's focus on restoring maximal health, critical in nursing to break readmission patterns and support long-term stability.