Nokea
The nurse is caring for an older client who had a cerebrovascular accident (CVA) several days ago. She is having trouble speaking. How should the nurse relate to this client?
- A. Encourage the client to speak and wait patiently while she tries
- B. Speak louder to the client
- C. Finish the client's sentences when she is having difficulty
- D. Tell the client to rest her voice for the next few days
Correct Answer: A
Rationale: Encouraging speech with patience supports recovery in aphasia post-CVA, unlike loud speech, finishing sentences, or voice rest, which hinder communication progress.
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Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?
- A. Potassium level
- B. Arterial blood gasses
- C. Blood urea nitrogen
- D. Thiocyanate
Correct Answer: D
Rationale: Thiocyanate. Nitroprusside metabolism increases thiocyanate levels, which can lead to cyanide toxicity if elevated.
The best method of evaluating the amount of peripheral edema is:
- A. Weighing the client daily
- B. Measuring the extremity
- C. Measuring the intake and output
- D. Checking for pitting
Correct Answer: B
Rationale: Measuring the extremity provides a direct and quantifiable assessment of peripheral edema by tracking changes in circumference. Daily weighing can indicate fluid retention but is less specific, so answer A is incorrect. Intake and output monitoring does not directly measure edema, so answer C is incorrect. Checking for pitting assesses the presence of edema but not its amount, so answer D is incorrect.
A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?
- A. Every time medication is administered
- B. When the client is symptomatic
- C. Before meals and at bedtime
- D. Every two hours
Correct Answer: C
Rationale: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.