Nokea
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.
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A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. diaphoresis with decreased urinary output
- B. increased heart rate with increased respirations
- C. improved respiratory status and increased urinary output
- D. decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.
A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?
- A. I need to wear a mask when I go out in public to prevent spreading the infection.
- B. I need to take my medication as prescribed to prevent spreading the infection to others.
- C. I need to cover my mouth when I cough to prevent spreading the infection.
- D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.
Correct Answer: A
Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.
Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
- A. Sensory perceptual alterations related to decreased vision
- B. Alteration in mobility related to fatigue
- C. Impaired gas exchange related to retained secretions
- D. Altered patterns of urinary elimination related to nocturia
Correct Answer: D
Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.
After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to suck on ice chips
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.
A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?
- A. Figs
- B. Broccoli
- C. Stewed tomatoes
- D. Skim milk
Correct Answer: D
Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.