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The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client?
- A. Keep the area between the toes dry.
- B. Wear comfortable, well-fitting shoes.
- C. Cut toenails straight across.
- D. A,B
Correct Answer: D
Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry to prevent moisture-related skin issues and wearing comfortable, well-fitting shoes to prevent injury and promote circulation. Cutting toenails straight across is important to prevent ingrown toenails, but in this case, an arch cut can lead to injury. Therefore, choices A and B are correct, making option D the most appropriate answer. Choice C is incorrect in this context.
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In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?
- A. Secure a clean container
- B. Discard the container if the outside becomes soiled
- C. Rinse the client's mouth with water after collection
- D. Tell the client that 4 tablespoons of sputum are needed
Correct Answer: A
Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.
During a physical assessment of a newborn, what finding should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A
Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?
- A. Flushing
- B. Dyspnea
- C. Tachycardia
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. This occurs due to the medication's stimulatory effect on beta-2 adrenergic receptors. Flushing (Choice A) is not a common side effect of albuterol. Dyspnea (Choice B) refers to difficulty breathing, which is a symptom albuterol aims to alleviate. Hypotension (Choice D) is not typically associated with albuterol use; instead, albuterol can lead to an increase in blood pressure.
Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour
- B. The client will have elastic skin turgor
- C. The client will have no adventitious breath sounds
- D. The client will have a serum creatinine of 1.4 mg/dL
Correct Answer: C
Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.
A true statement about medications is that:
- A. Over-the-counter medications are unlikely to interact with food or nutrients
- B. Prescription medications always have significant interactions with food
- C. Prescription and nonprescription drugs and herbal remedies interact with food
- D. Herbal products are generally safe since they are natural
Correct Answer: C
Rationale: The correct answer is C. This statement is true because both prescription and over-the-counter medications, as well as herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is incorrect because natural herbal products can also have side effects and interactions with other substances.