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The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
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A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
The nurse is caring for a client with heart failure.
- A. Which symptom indicates worsening heart failure in a client?
- B. Weight gain of 2 pounds in 24 hours.
- C. Decreased blood pressure.
- D. Clear lung sounds bilaterally.
- E. Improved exercise tolerance.
Correct Answer: A
Rationale: A weight gain of 2 pounds in 24 hours indicates fluid retention, a sign of worsening heart failure. Decreased blood pressure may occur but is less specific, clear lung sounds suggest stability, and improved exercise tolerance indicates improvement.
The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
- A. Dry mouth
- B. Weak muscles
- C. Sore throat
- D. Irritated nose
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild epigastric discomfort.
- B. Occasional heartburn.
- C. Black, tarry stools.
- D. Nausea after meals.
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Correct Answer: D
Rationale: Middle childhood (ages 6-12) is associated with the developmental task of industry, where children focus on competence and achievement.