Nokea
The nurse is caring for a client with a long history of taking magnesium hydroxide for managing symptoms of peptic ulcer disease. Which finding in the client's medical history would be of concern to the nurse?
- A. asthma
- B. arthritis
- C. heart failure
- D. enlarged prostate
Correct Answer: C
Rationale: Magnesium hydroxide can cause fluid retention, worsening heart failure. Other conditions are not directly affected.
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The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using:
- A. A toothbrush
- B. A soft gauze pad
- C. Antiseptic mouthwash
- D. Lemon and glycerin swabs
Correct Answer: B
Rationale: A soft gauze pad is gentle and effective for cleaning the mouth in oral candidiasis without causing trauma.
Which of the following best describes the language of a 24-month-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of words
- C. Able to verbalize needs
- D. Asks 'why?' to most statements
Correct Answer: C
Rationale: A 24-month-old can verbalize needs using simple words or phrases, reflecting their developing language skills.
The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?
- A. Frothy hemoptysis
- B. Trachea shift toward the unaffected side of the chest
- C. Subcutaneous emphysema noted at the anterior chest
- D. Opening chest wound with a whistle sound emitting from the area
Correct Answer: B
Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
- A. AÂ W client with a stroke with tube feedings
- B. A client with congestive heart failure complaining of nighttime dyspnea
- C. A client with a thoracotomy six months ago
- D. A client with Parkinson's disease
Correct Answer: B
Rationale: Nighttime dyspnea suggests acute heart failure exacerbation, requiring priority.