Nokea
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
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In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
The nurse is caring for a client with a history of myocardial infarction.
- A. Which instruction is most important for a client post-myocardial infarction?
- B. Avoid heavy lifting for 6 weeks.
- C. Take nitroglycerin only when chest pain occurs.
- D. Resume normal activity immediately.
- E. Monitor blood pressure weekly.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any skin rash
- C. Stop the medication if seizures stop
- D. Avoid regular blood Test s
Correct Answer: B
Rationale: A skin rash may indicate Stevens-Johnson syndrome, a serious lamotrigine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks seizures, and blood Test s are needed.
A preschool client's mother reports that the child has frequent bouts of gastroenteritis.
It would be MOST important for the nurse to ask which of the following questions?
- A. Are there other children in the family?'
- B. Does the child attend a day care center?'
- C. Does the child play with neighborhood children?'
- D. Is the child current on his immunizations?'
Correct Answer: B
Rationale: Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct-environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission (3) possible source of infection, but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
- A. What is the most important nursing care plan inclusion for an elderly client post-femoral fracture repair?
- B. Eat a high-protein, low-residue diet.
- C. Lie on her unoperated side.
- D. Exercise her arms and legs.
- E. Cough and deep breathe.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.