Nokea
The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
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The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Avoid folic acid supplements.
- C. Report any fever or sore throat.
- D. Stop the medication if joint pain decreases.
Correct Answer: C
Rationale: Methotrexate can cause bone marrow suppression; fever or sore throat may indicate infection, requiring reporting. Options A, B, and D are incorrect.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
- A. Oxygen saturation of 90%.
- B. Respiratory rate of 20 breaths/min.
- C. Temperature of 101°F (38.3°C).
- D. Heart rate of 80 bpm.
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL).
Which of the following nursing actions should have the highest priority?
- A. Keep a tongue blade at the bedside.
- B. Encourage the child to participate in play therapy.
- C. Apply cool soaks to the injection site.
- D. Rotate the injection sites.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct-highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion