Nokea
Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
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A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
- A. Wound tissue firm to palpation
- B. Dry brown eschar
- C. Light yellow exudate
- D. Dark red granulation tissue
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
- A. Limit the client's fluid intake.
- B. Measure blood glucose every 2 hr.
- C. Instruct the client to expect tingling in their extremities.
- D. Instruct the client to lie flat.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to lie flat. This is important to prevent post-lumbar puncture headache by promoting the closure of the dural puncture site. Lying flat helps reduce the risk of cerebrospinal fluid leakage and subsequent headache. Limiting fluid intake (A) is not necessary post-lumbar puncture. Monitoring blood glucose (B) is not directly related to lumbar puncture care. Expecting tingling in extremities (C) is not a common post-lumbar puncture symptom.
A nurse is providing teaching to a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: Correct Answer: C. Increase water intake and use bulk-forming laxatives.
Rationale: Increasing water intake helps soften stool, easing constipation in IBS-C. Bulk-forming laxatives add fiber to stool, improving bowel movements. Stimulant laxatives (A) can lead to dependency. Avoiding fiber-rich foods (B) worsens constipation. A low-carbohydrate diet (D) may exacerbate constipation.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
- A. Limit fluid intake to 1,000 mL per day.
- B. Administer oxygen at 2 L/min.
- C. Encourage use of incentive spirometry for 5 min every 2 hr.
- D. Teach the client a breathing exercise with a longer inhalation phase.
Correct Answer: D
Rationale: The correct answer is D. Teaching the client a breathing exercise with a longer inhalation phase helps improve lung capacity and strengthen respiratory muscles, which are essential for clients with emphysema. This intervention can help the client breathe more effectively and reduce shortness of breath. Option A is incorrect because limiting fluid intake is not a standard intervention for emphysema. Option B is incorrect as administering oxygen is not specific to improving lung function. Option C is incorrect as incentive spirometry is more effective if done for longer durations.