Nokea
The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?
- A. Blood pressure of 150/90 mmHg
- B. Irregular heart rhythm
- C. Shortness of breath
- D. Fatigue
Correct Answer: C
Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.
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If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?
- A. "I will get the caller off the phone as soon as possible so I can alert the staff."
- B. "I will begin evacuating clients using the elevators."
- C. "I will not ask any questions and just let the caller talk."
- D. "I will listen for background noises."
Correct Answer: D
Rationale: The correct answer is D: "I will listen for background noises." Listening for background noises can provide useful information about the bomb's location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.
A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
- B. I will hold my breath when rising from a sitting position.
- C. I will remove my antiembolic stockings while I am in bed.
- D. I will have my partner help me change positions every 4 hours.
Correct Answer: A
Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.
A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin in the same body area each time.
- B. Store the insulin according to the manufacturer's instructions.
- C. Rotate injection sites within the same body area.
- D. Inject the insulin at a 45-degree angle.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.
Postoperative client with fluid volume deficit. Which change indicates successful treatment?
- A. Decrease in heart rate
- B. Increase in blood pressure
- C. Decrease in respiratory rate
- D. Increase in urine output
Correct Answer: A
Rationale: A decrease in heart rate can indicate improved fluid balance and successful treatment of fluid volume deficit. When a client is experiencing fluid volume deficit, the heart rate typically increases as a compensatory mechanism to maintain cardiac output. As fluid volume is restored and the deficit is corrected, the heart rate should decrease back towards a normal range. Choices B, C, and D are less likely to be directly related to the successful treatment of fluid volume deficit. An increase in blood pressure may occur as a compensatory response to fluid volume deficit; a decrease in respiratory rate is not a typical indicator of fluid volume deficit correction; and an increase in urine output can be a sign of improved kidney function but may not directly reflect fluid volume status.
A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?
- A. It decreases the risk of injecting medication into a blood vessel.
- B. It delays medication absorption.
- C. It minimizes tissue irritation.
- D. It accelerates medication excretion.
Correct Answer: C
Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.