Nokea
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
- A. Pain
- B. Impaired gas exchange
- C. Cardiac output altered: decreased
- D. Fluid volume excess
Correct Answer: C
Rationale: Cardiac output altered: decreased. Increasing cardiac output is the primary goal of therapy, improving comfort and respiratory status.
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A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?
- A. Administer the medication around the clock even if the client denies having pain
- B. Avoid administering with immediate-release opioids to prevent respiratory depression
- C. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs
- D. Request a tapered dose from the health care provider if pain decreases to prevent tolerance
Correct Answer: A
Rationale: Around-the-clock dosing maintains pain control in cancer, preventing peaks and troughs. Combining with immediate-release opioids is common, dosage changes require provider orders, and tapering is less critical in terminal care.
A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
The nurse is caring for a client with type 2 diabetes mellitus who is receiving a thiazolidinedione. Which of the following findings would require immediate follow-up?
- A. 2+ pitting edema in the lower legs bilaterally
- B. blood pressure of 140/88 mm Hg
- C. elevated triglyceride level
- D. elevated hemoglobin A1c
Correct Answer: A
Rationale: Thiazolidinediones (eg, rosiglitazone, pioglitazone) are oral antidiabetic medications used to manage hyperglycemia in clients with type 2 diabetes mellitus. Thiazolidinediones increase the sensitivity of insulin receptors, which improves insulin efficacy and prevents large rises in blood glucose after meals. It is a priority for the nurse to report signs of heart failure (eg, bilateral pitting edema, rapid weight gain, crackles) to the health care provider because thiazolidinediones can cause heart failure due to fluid retention. The client may require a lower thiazolidinedione dose or therapy with a different oral antidiabetic agent (eg, metformin).