Nokea
The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
- A. S3 heart sound
- B. Murmur
- C. S4 heart sound
- D. Hypoventilation
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
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The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?
- A. 150 cc.
- B. 210 cc.
- C. 295 cc.
- D. 385 cc.
Correct Answer: A
Rationale: 445-235=210-60=150
A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?
- A. I have been having difficulty with my hearing.'
- B. I lose my balance easily.'
- C. I can't tell the difference between a sweet and sour taste.'
- D. It is not easy for me to remember names and faces.'
Correct Answer: B
Rationale: Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct-cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptoms of cerebellum dysfunction
The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?
- A. Wine, beer, cheese, liver and chocolate
- B. Wine, citrus fruits, yogurt and broccoli
- C. Beer, cheese, beef and carrots
- D. Wine, apples, sour cream and beef steak
Correct Answer: A
Rationale: These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.