Nokea
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.
You may also like to solve these questions
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.
Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I will drink plenty of water every day
- B. I should take a low-dose aspirin every day
- C. I need to have blood removed periodically
- D. I will continue taking my daily multivitamin with iron
Correct Answer: D
Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.
The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.
- A. Digging in a sandbox
- B. Finger painting
- C. Playing a board game
- D. Playing soccer
- E. Pushing toy cars
Correct Answer: A,B,E
Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.
The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.