Nokea
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
- A. Impaired skin integrity related to dependent edema
- B. Activity intolerance related to oxygen supply and demand imbalance
- C. Constipation related to immobility
- D. Risk for infection related to ineffective mobilization of secretions
Correct Answer: B
Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
You may also like to solve these questions
A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.
After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.
The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?
- A. Captopril
- B. Carvedilol
- C. Glipizide
- D. Levothyroxine
Correct Answer: D
Rationale: Levothyroxine (D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (A), Carvedilol (B), and Glipizide (C) are less likely to cause significant ECG alterations.
Laboratory reference ranges
Glucose (fasting)
Infant – Within 24 hours after birth
≥40 mg/dL (2.2 mmol/L)
The nurse is caring for assigned newborns. Which of the following newborns should the nurse check first?
- A. a newborn who was delivered 30 minutes ago and has bilateral crackles
- B. a newborn who was delivered 45 minutes ago and has asymmetric arm movement when the Moro reflex is tested
- C. a newborn who was delivered 6 hours ago and has a respiratory rate of 52/min
- D. a newborn who was delivered 12 hours ago, is jittery, and has a serum glucose level of 38 mg/dL (2.1 mmol/L)
Correct Answer: D
Rationale: A glucose level of 38 mg/dL with jitteriness (D) indicates hypoglycemia, a critical condition requiring immediate intervention. Crackles (A), asymmetric Moro reflex (B), and respiratory rate of 52 (C) are less urgent.