Nokea
The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate?
- A. Maintain and improve the quality of oxygenation.
- B. Improve the status of ventilation.
- C. Increase oxygenation of peripheral circulation.
- D. Correct the bicarbonate deficit.
Correct Answer: B
Rationale: to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
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The nurse in the outpatient clinic teaches a young adult with a sprained right ankle to walk with a cane. While teaching the client to use the cane, how should the nurse be positioned?
- A. Standing on the client's left side and slightly behind the client.
- B. Standing on the client's right with one hand on the client's waist.
- C. Standing directly in front of the woman with both hands on the client's arms.
- D. Standing in front of the client on the right side.
Correct Answer: A
Rationale: stand slightly behind patient on strong side
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
- A. Which finding indicates a possible complication in a 23-year-old woman at 32-weeks gestation?
- B. The client’s urine Test is positive for glucose and acetone.
- C. The client has 1+ pedal edema in both feet at the end of the day.
- D. The client complains of an increase in vaginal discharge.
- E. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Glucose and acetone in urine suggest possible gestational diabetes, which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Mild edema, increased vaginal discharge, and diaphragmatic pressure are common in late pregnancy and not necessarily indicative of complications.
While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset