Nokea
The nurse is assessing a client's activity tolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?
- A. Pulse rate increased by 20 beats per minute (bpm) immediately after the activity.
- B. Respiratory rate decreased by 5 breaths/minute.
- C. Diastolic blood pressure increased by 7 mm Hg.
- D. Pulse rate within 6 bpm of resting pulse after 3 minutes of rest.
Correct Answer: B
Rationale: A decrease in respiratory rate after exercise is abnormal, as physical activity typically increases respiratory demand to meet oxygen needs. A pulse increase of 20 bpm, a slight rise in diastolic blood pressure, and a near-return to resting pulse after 3 minutes are normal responses to moderate exercise.
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The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is more relevant for hepatitis A. Syringe disposal (B) applies to needle-sharing risks, and alpha-interferon (C) is treatment, not prevention.
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
- A. Suction the airway.
- B. Administer oxygen at 6 L/min.
- C. Reposition the client to a lateral position.
- D. Increase I.V. fluids.
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
The nurse is planning a staff development conference about medication reconciliation. Which of the following information should the nurse include?
- A. Obtain a list of the medications instead of reviewing the list with the client
- B. Medication reconciliation should occur just at discharge to prevent omissions.
- C. Prescribed medications should be obtained and omit herbs and supplements.
- D. This process should occur at admission, client transfer, and discharge.
Correct Answer: C
Rationale: Medication reconciliation at admission, transfer, and discharge ensures accuracy and continuity of care.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.