Nokea
The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?
- A. Peripheral edema
- B. Jugular vein distention
- C. Shortness of breath
- D. Weight gain
Correct Answer: C
Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.
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The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?
- A. Deltoid muscle
- B. Inner forearm
- C. Abdomen
- D. Thigh
Correct Answer: B
Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.
A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?
- A. Daily weight
- B. Electrolyte levels
- C. Urine output
- D. All of the above
Correct Answer: D
Rationale: Monitoring daily weight, electrolyte levels, and urine output is crucial in evaluating treatment effectiveness for heart failure. Daily weight monitoring helps assess fluid retention or loss, changes in electrolyte levels can indicate imbalances affecting heart function, and urine output monitoring provides insights into kidney function and fluid balance. Therefore, all options are essential components in assessing the patient's fluid status and response to treatment, making 'All of the above' the correct answer. Choices A, B, and C are incorrect individually as they only represent partial aspects of monitoring heart failure treatment effectiveness.
Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?
- A. Application of topical antibacterial cream
- B. Use of careful hand washing technique
- C. Administration of plasma expanders
- D. Limiting visitors to the burned client
Correct Answer: B
Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.
The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?
- A. Encourage the client to eat foods high in protein
- B. Assess the client for daily range of motion exercises
- C. Teach the family how to perform sterile wound care
- D. Ensure the IV fluids are administered as prescribed
Correct Answer: A
Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.
A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?
- A. Offer information about the procedure steps
- B. Administer an anxiolytic before the procedure
- C. Encourage the client to discuss their fears
- D. Reassure the client that the procedure is common and safe
Correct Answer: C
Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.