Nokea
The nurse is assessing a client with suspected pulmonary edema. Which finding supports this diagnosis?
- A. Crackles in lung bases
- B. Dry cough
- C. Clear lung sounds
- D. Bradycardia
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in the alveoli, a key sign of pulmonary edema requiring urgent intervention.
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A client asks the nurse why he was asked to complete an advance directive when he entered the hospital. The nurse's best response is which of the following?
- A. This will provide a substitute for informed discussion with the physician.'
- B. It is a legal requirement for all clients entering a hospital to be offered the chance to make an advance directive.'
- C. The physician will make the best decisions for you in an emergency.'
- D. Are you worried that extraordinary means will be taken if you are dying?'
Correct Answer: B
Rationale: It is a legal requirement in many regions for hospitals to offer patients the opportunity to complete an advance directive upon admission to ensure their wishes are documented.
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
- A. Tachycardia
- B. Hypertension
- C. Warm, dry skin
- D. Bradypnea
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
When determining the parents' compliance with treatment for their child's ear infection, the nurse should ask the parents if they are:
- A. Cleaning the child's ear canals with hydrogen peroxide.
- B. Administering continuous, low-dose antibiotic therapy.
- C. Instilling ear drops regularly to prevent cerumen accumulation.
- D. Holding the child upright when feeding with a bottle.
Correct Answer: D
Rationale: Holding the child upright during feeding prevents milk from entering the Eustachian tube, reducing ear infection risk.