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The nurse is caring for a client with a history of congestive heart failure.
- A. Which instruction is most important for a client with congestive heart failure?
- B. Weigh yourself daily at the same time.
- C. Take extra diuretics if you feel short of breath.
- D. Eat a high-sodium diet to maintain electrolytes.
- E. Avoid exercise to prevent cardiac strain.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
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A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST?
- A. Cover your mouth and nose when you sneeze or cough.
- B. Eat in a separate room away from your family.
- C. Don't share your drinking glass or silverware with anybody.
- D. Stay in your room until all of your symptoms are gone.
Correct Answer: C
Rationale: symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
- A. Send the staff member home.
- B. Assess the staff member's compliance with standard precautions.
- C. Assign the staff member only to clients with chronic diseases.
- D. Re-assign the staff member to clean the supply closet.
Correct Answer: A
Rationale: extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3-7 days
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)