Nokea
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
- A. An increase in urine output
- B. A decrease in blood pressure
- C. A decrease in heart rate
- D. Warm, moist skin
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.
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A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client?
- A. Nasal cannula
- B. Non-rebreathing mask
- C. Oxymizer
- D. Venturi mask
Correct Answer: D
Rationale: A Venturi mask (D) delivers precise oxygen concentrations, ideal for COPD exacerbation to avoid hypercapnia. Nasal cannula (A), non-rebreathing mask (B), and Oxymizer (C) are less precise.
A nurse is reinforcing teaching to a client that breastfeeds who has been diagnosed with mastitis of the right breast. Which of the following instructions should be included? Select all that apply.
- A. Cease breastfeeding from right breast
- B. Increase oral fluid intake
- C. Reduce frequency of feeds to every 8 hours in right breast
- D. Take ibuprofen as needed for pain
- E. Use a tight-fitting underwire bra 24 hours per day
Correct Answer: B, D
Rationale: Increased fluids (B) and ibuprofen (D) manage dehydration and pain. Ceasing breastfeeding (A) or reducing feeds (C) can worsen mastitis, and tight bras (E) may increase discomfort.
The nurse is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse administer to the client? Select all that apply.
- A. albuterol
- B. buproten
- C. ipratropium
- D. tobramycin
- E. montelukast
Correct Answer: A, C
Rationale: Albuterol (A) and ipratropium (C) are bronchodilators used in acute asthma exacerbations. Ibuprofen (B), tobramycin (D), and montelukast (E) are not indicated for acute management.
The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.