Nokea
The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
- A. Assess respiratory status.
- B. Draw blood for laboratory studies.
- C. Insert a Foley catheter.
- D. Weigh the client.
Correct Answer: A
Rationale: Edema and left ventricular enlargement suggest heart failure, which can cause pulmonary edema. Assessing respiratory status first detects signs of respiratory distress.
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Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
Cortisone acetate (Cortone) and fludrocortisone acetate (Florinef Acetate) are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy?
- A. Take both drugs three times a day.
- B. Take the entire dose of both drugs first thing in the morning.
- C. Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon.
- D. Take half of each drug in the morning and the remaining half of each drug at bedtime.
Correct Answer: C
Rationale: Mimicking diurnal cortisol patterns, most cortisone and all fludrocortisone are taken in the morning, with the remaining cortisone in the afternoon.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement?
- A. Ambulating in the hallway.
- B. Sitting up in a chair.
- C. Lying in bed and taking deep breaths.
- D. Using a stationary bicycle in the room.
Correct Answer: C
Rationale: Improving tidal volume and activity tolerance requires active movement to enhance lung expansion and stamina. Ambulating, sitting up, and using a stationary bicycle promote these outcomes. Lying in bed, even with deep breaths, is passive and least effective.