Nokea
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:
- A. Pain.
- B. Impaired gas exchange.
- C. Decrease Cardiac output.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Impaired gas exchange is the main issue in pulmonary edema.
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The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding.
- B. Involuntary voiding with coughing and sneezing.
- C. Frequent urination.
- D. Urine is dark and concentrated.
Correct Answer: C
Rationale: Frequent urination is common due to urethral obstruction.
A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?
- A. Restrict the client's fluid intake.
- B. Assess the client's respiratory status.
- C. Administer diuretics as ordered.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. The first action should be to assess the client's respiratory status as the weight gain could indicate fluid retention leading to pulmonary congestion, a common complication in heart failure. By assessing the respiratory status, the nurse can determine if there are signs of respiratory distress such as increased work of breathing, crackles, or shortness of breath. This assessment will help in identifying any immediate need for interventions such as oxygen therapy or diuretics. Restricting fluid intake (choice A) is important but not the first step. Administering diuretics (choice C) should be based on assessment findings. Notifying the healthcare provider (choice D) can be done after assessing the client's respiratory status.
Place the steps for removal of a foreign body from the ear canal in the correct order.
- A. Refer for treatment of external otitis.
- B. Inspect the tympanic membrane for trauma.
- C. Obtain history for type of object.
- D. Choose appropriate fluid for irrigation or instillation.
Correct Answer: C
Rationale: Obtaining a history helps determine the safest method for removing the foreign body and prevents further injury.
It is hospital policy to assess and record a patient's heart rate before administering digoxin (Lanoxin). By auditing the nursing records to determine the frequency of compliance with this policy, the quality assessment and improvement committee is conducting
- A. a process analysis.
- B. a quality analysis.
- C. a system analysis.
- D. an outcome analysis.
Correct Answer: A
Rationale: Process analysis focuses on evaluating adherence to specific procedures.
A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?
- A. Blood glucose level
- B. Serum sodium level
- C. Serum calcium level
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: The correct answer is A: Blood glucose level. The healthcare professional should check the blood glucose level first because hypoglycemia or hyperglycemia can cause confusion. Hypoglycemia can lead to altered mental status quickly and should be ruled out immediately. Checking the serum sodium level (B), serum calcium level (C), or blood urea nitrogen (D) can be important in further assessment, but addressing the blood glucose level is the primary concern in this scenario to rule out any immediate life-threatening conditions related to glucose imbalance.