Nokea
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
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The nurse is to move a client up in bed without any help. Where should the nurse place the client's pillow?
- A. At the bottom of the bed
- B. On the bedside stand
- C. At the head of the bed
- D. Under the client's head
Correct Answer: C
Rationale: Placing the pillow at the head of the bed supports the client's head after moving up, ensuring comfort and proper positioning.
The nurse is caring for a client with a history of peptic ulcer disease.
- A. Which dietary instruction is most appropriate for a client with peptic ulcer disease?
- B. Avoid spicy foods and caffeine.
- C. Eat large meals three times daily.
- D. Consume high-fat foods to coat the stomach.
- E. Drink alcohol in moderation.
Correct Answer: A
Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy?
- A. A padded tongue
- B. An endotracheal tube
- C. An airway
- D. A tracheostomy set
Correct Answer: D
Rationale: A tracheostomy set is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy. Options A, B, and C are less critical in this context.
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 200 mg/dL.
- B. Potassium of 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium of 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.