Nokea
The nurse is caring for a client with a history of congestive heart failure (CHF). Which of the following findings would indicate to the nurse that the client's condition is worsening?
- A. Clear lung sounds bilaterally.
- B. Weight gain of 2 pounds in 24 hours.
- C. Urine output of 1,200 mL in 24 hours.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: weight gain is a sign of fluid retention, indicating worsening CHF
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The nurse is caring for a client with a history of peptic ulcer disease who is receiving omeprazole (Prilosec) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache once in a while.
- B. I feel bloated after meals.
- C. I have black, tarry stools.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Black, tarry stools suggest gastroinTest inal bleeding, a serious complication in peptic ulcer disease requiring immediate evaluation. Options A, B, and D are less concerning: headaches are nonspecific, bloating is common, and taking omeprazole with food is acceptable.
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin
The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
An older man is seen in the outpatient clinic for treatment of an acute attack of gout.
- A. Which nursing intervention is most beneficial for decreasing pain during ambulation in a client with gout?
- B. Perform passive range-of-motion exercises before walking.
- C. Encourage partial weight bearing while ambulating.
- D. Immobilize the extremity between activities.
- E. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: Partial weight bearing reduces pressure and stress on the affected joint, alleviating gout-related pain during ambulation. Passive exercises may worsen pain, immobilization increases stiffness, and restricting walking does not address pain management during necessary movement.
Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
- A. The gene came from my husband's side of the family.
- B. The gene came from my wife's side of the family.
- C. There is a 50 percent chance that our next child will have the disease.
- D. Both of us carry a recessive trait for cystic fibrosis.
Correct Answer: D
Rationale: cystic fibrosis is inherited by an autosomal recessive trait