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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles in lungs
- B. Decreased thirst
- C. Poor skin turgor
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (B) is not a typical manifestation. Poor skin turgor (C) is more indicative of dehydration. Tachycardia (D) may occur but is not specific to heart failure.
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A nurse is teaching a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.'
- B. My provider will make my health care decisions if I complete advance directives.'
- C. Advance directives outline who inherits my material possessions in the event of my death.'
- D. My partner needs to be present as a witness when I sign a living will.'
Correct Answer: A
Rationale: The correct answer is A because it accurately defines a living will as a document stating the client's healthcare wishes. This shows understanding of an advance directive's purpose. Option B is incorrect because advance directives empower the client, not the provider, to make healthcare decisions. Option C is incorrect as advance directives focus on healthcare, not material possessions. Option D is incorrect as witnesses don't need to be partners, just competent adults.
A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure?
- A. Prone
- B. Trendelenburg
- C. High-Fowler's
- D. Right lateral
Correct Answer: D
Rationale: The correct answer is D: Right lateral. Placing the client in a right lateral position post-liver biopsy helps prevent bleeding or hemorrhage by exerting pressure on the biopsy site, aiding in hemostasis. This position also reduces the risk of complications such as pneumothorax. Placing the client in a prone position (A) could increase the risk of bleeding. Trendelenburg position (B) may increase intra-abdominal pressure and the risk of bleeding. High-Fowler's position (C) is not ideal for post-liver biopsy care as it does not provide the necessary pressure to the biopsy site.
A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B12
- C. Vitamin K
- D. Metoclopramide
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Following a total gastrectomy, the client will have reduced intrinsic factor production, leading to vitamin B12 deficiency. Supplementing with Vitamin B12 is crucial to prevent pernicious anemia. Ranitidine (A) is a gastric acid reducer and is not necessary after gastrectomy. Vitamin K (C) is primarily produced in the intestines and is not directly impacted by gastrectomy. Metoclopramide (D) is a prokinetic agent used for gastric motility and is not essential post-gastrectomy.
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.