Nokea
The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.
- A. obtain daily weight
- B. provide assistance with self-care activities
- C. provide sensory stimulation
- D. check vital signs after activity
Correct Answer: A, B, D
Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.
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A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
- A. You will be sitting for the examination procedure.
- B. Portions of the procedure will cause pain or discomfort.
- C. You will be asleep during the procedure.
- D. You will not be able to drink fluids for 24 hours following the study.
Correct Answer: B
Rationale: Renal biopsies may cause discomfort during needle insertion, and informing the client prepares them for the procedure.
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer vitamin K as a reversal agent.
- D. Recheck the INR in 4 hours.
Correct Answer: B
Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
The nurse is preparing to administer a dose of hydralazine (Apresoline) to a client with hypertension. The client’s blood pressure is 90/60 mmHg. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and recheck the blood pressure.
- D. Recheck the blood pressure in 30 minutes.
Correct Answer: B
Rationale: hydralazine is a vasodilator, and a blood pressure of 90/60 mmHg indicates hypotension, so the dose should be withheld
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
- A. Herbals can interfere with the action of antiviral medication
- B. Supplements have proven effective in prolonging life
- C. Herbals have been shown to decrease the viral load
- D. Supplements appear to prevent replication of the virus
Correct Answer: A
Rationale: Echinacea may interact with antiretroviral medications, potentially reducing their effectiveness.