Nokea
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.
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When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Lochia rubra with small clots.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
A client with a cholesterol level of $240 \mathrm{mg}$ is instructed to modify his diet. Which of the following diets provides a low-cholesterol, low-saturated fat breakfast?
- A. Oatmeal, skim milk, toast with margarine, orange juice, coffee
- B. French toast, margarine, syrup, crisp bacon, coffee
- C. Pancake, margarine, syrup, sausage, fresh fruit, tea
- D. Toasted bagel, cream cheese, poached egg, coffee
Correct Answer: A
Rationale: Oatmeal, skim milk, and margarine are low in cholesterol and saturated fat, unlike bacon, sausage, or cream cheese.
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Which of the following responses, if made by the nurse, is BEST?
- A. You can trust me. There are no agents here.'
- B. You must feel afraid if you believe that, but there are no agents here.'
- C. No one here will hurt you. They are here to help you.'
- D. Agents? Tell me more about what you mean.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them