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The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
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The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?
- A. During a left heart catheterization, the coronary arteries can be visualized.
- B. During a left heart catheterization, holes in the heart walls can be detected.
- C. During a left heart catheterization, blood flow to the lungs can be measured.
- D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.
Correct Answer: A
Rationale: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.
The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.
Laboratory results
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L) 58 mg/dL
(3.2 mmol/L)
The nurse is caring for a client with type 2 diabetes mellitus who reports feeling lightheaded and shaky. Which of the following actions should the nurse take next?
- A. Administer glucagon by subcutaneous injection as prescribed
- B. Administer rapid-acting insulin per sliding scale as prescribed
- C. Give the client 4 oz (120 mL) of fruit juice or a regular soft drink
- D. Give the client a snack of cheese or peanut butter with crackers
Correct Answer: C
Rationale: Lightheadedness and shakiness suggest hypoglycemia. Providing 15 grams of fast-acting carbohydrates, such as 4 oz of fruit juice, is the first-line treatment to raise blood glucose levels quickly.
The nurse has reinforced teaching for a client with newly diagnosed von Willebrand disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I can use a humidifier to help prevent nosebleeds.
- B. I need to wear gloves while doing yard work.
- C. I should use a soft-bristled toothbrush and floss carefully.
- D. I will notify my health care provider if I soak a menstrual pad in an hour.
- E. I will take NAPROXEN to decrease pain and inflammation if I am injured.
Correct Answer: A,C,D
Rationale: Using a humidifier (A) prevents mucosal drying and nosebleeds. A soft-bristled toothbrush and careful flossing (C) minimize gum bleeding. Reporting heavy menstrual bleeding (D) is critical to manage bleeding risks in von Willebrand disease.
The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply.
- A. Ask open-ended questions
- B. Move close to the client and speak in a loud voice
- C. Remove background noise by turning off the television
- D. Touch the client on shoulder prior to speaking
- E. Use clear and simple sentences
Correct Answer: C,D,E
Rationale: Reducing background noise (C) minimizes distractions. Touching the shoulder (D) gains attention non-verbally. Using clear, simple sentences (E) accommodates cognitive impairments in Alzheimer disease.