Nokea
The nurse is caring for a client with left-sided heart failure. Which assessment findings does the nurse anticipate for this client? Select all that apply.
- A. dyspnea
- B. engorged spleen
- C. dependent edema
- D. jugular vein distention
- E. weak peripheral pulses
- F. crackles or wheezes in the lungs
Correct Answer: A,C,F
Rationale: Left-sided heart failure causes pulmonary congestion, leading to dyspnea (A), dependent edema (C), and crackles/wheezes (F). Spleen engorgement (B), jugular vein distention (D), and weak pulses (E) are more typical of right-sided failure.
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The nurse is reviewing labs on a client with second- and third-degree burns from a house fire. Which abnormal lab value would the nurse expect to find with this client?
- A. pH of 7.41
- B. albumin of 3.9 g/dL
- C. hemoglobin of 15 g/dL
- D. potassium of 5.9 mEq/L
Correct Answer: D
Rationale: Burns cause cell damage, releasing potassium, leading to hyperkalemia (5.9 mEq/L, D). pH 7.41 (A), albumin 3.9 (B), and hemoglobin 15 (C) are within normal ranges.
Which of the following is not a recommended preparation for electroconvulsive therapy (ECT)?
- A. premedication with an anticholinergic agent
- B. morning bath, NPO after midnight
- C. informed consent in writing
- D. administration of an anticonvulsant 30 minutes before ECT
Correct Answer: D
Rationale: Anticonvulsants (D) are not given before ECT, as seizures are therapeutic. Anticholinergics (A), NPO/bath (B), and consent (C) are standard preparations.
A client is 2 hours post-op for a right total knee replacement. Upon assessment by the nurse, which information requires notification of the doctor?
- A. hemoglobin is 10.2 grams per liter
- B. bleeding on the dressing of 2 cm
- C. oral temperature of 100.4°F
- D. complaint of pain at incision site
Correct Answer: A
Rationale: Hemoglobin of 10.2 g/L (A) indicates significant blood loss requiring notification. Minor bleeding (B), low-grade fever (C), and expected pain (D) are less urgent.
The nurse is caring for a client who is HIV-positive. The nurse understands which of the following to be true regarding HIV and AIDS?
- A. Viral load testing monitors disease progression and evaluates effectiveness of treatment.
- B. The Western blot test is positive if antibodies to at least three major HIV antigens are present.
- C. Patients with AIDS present with a white blood cell (WBC) count between 5,000 and 10,000 cells/mm³.
- D. An enzyme-linked immunosorbent assay (ELISA) test can detect the presence of antibodies within 2 weeks of exposure.
Correct Answer: A
Rationale: Viral load testing (A) monitors HIV progression and treatment efficacy. Western blot requires two antigens (B), AIDS involves low CD4 counts, not WBC (C), and ELISA detects antibodies after 3-12 weeks (D).
The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?
- A. 9
- B. 10
- C. 11
- D. 12
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain = 2, localizes pain = 5, inappropriate words = 2. Total = 2 + 5 + 2 = 9 (A).