Nokea
The nurse teaches a client with chronic obstructive pulmonary disease for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan?
- A. Clubbing of nail beds.
- B. Hypertension.
- C. Peripheral edema.
- D. Increased appetite.
Correct Answer: C
Rationale: Right-sided heart failure (cor pulmonale) in COPD causes peripheral edema due to increased venous pressure. Clubbing reflects chronic hypoxia, not heart failure. Hypertension and increased appetite are unrelated.
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A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
An adult client with type 2 diabetes is taking metformin (Glucophage) 1,000 mg two times every day. After the nurse provides instructions regarding the interaction of alcohol and metformin, the nurse evaluates that the client understands the instructions when the client says:
- A. If I know I'll be having alcohol, I must not take metformin; I could develop lactic acidosis.'
- B. If my physician approves, I may drink alcohol with my metformin.'
- C. Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat.'
- D. If I feel bloated, I should call my physician.'
Correct Answer: A
Rationale: Alcohol combined with metformin increases the risk of lactic acidosis, a serious complication. The client should avoid alcohol while taking metformin.
A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: In pancreatitis, fluid sequestration into the retroperitoneal space (B) causes hypovolemia, complicating shock management. Intestinal hemorrhage (A), infection (C), and decreased cardiac output (D) are less primary contributors.
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.