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The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
- A. 90 percent of clients have not gained weight.
- B. 75 percent of the clients viewed the educational video.
- C. 80 percent of the clients reported that they are taking their medications.
- D. 5 percent of the clients required hospitalization in the last 90 days.
Correct Answer: A,C,D
Rationale: No weight gain (A), medication adherence (C), and low hospitalization rates (D) indicate effective management of heart failure through monitoring and teaching.
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A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
- A. Dissolves stones.
- B. Relaxes ureter muscles.
- C. Reduces urine output.
- D. Prevents infection.
Correct Answer: B
Rationale: Tamsulosin relaxes ureter muscles, aiding stone passage.
Which assessment is most important for a client receiving mannitol?
- A. Blood pressure.
- B. Urine output.
- C. Pain level.
- D. Pupil response.
Correct Answer: B
Rationale: Urine output is critical to monitor for mannitol's diuretic effect in reducing intracranial pressure.
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
- A. Bowel obstruction
- B. Paralytic ileus
- C. Peritonitis
- D. Wound dehiscence
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.