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Tom is diagnosed with congestive heart failure and asks why fluid accumulates in his lungs. You respond by saying
- A. Because of the excessive volume of IV fluid that is being administered.
- B. The right side of your heart is weakened and is losing the capability to pump blood to your lungs.
- C. You stand too long at work.
- D. The left side of your heart is weakened and is losing the capability to pump blood to your lungs.
Correct Answer: D
Rationale: Left-sided heart failure leads to pulmonary congestion as blood backs up in the lungs.
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The nurse knows that the most likely cause of the HSV-1 infection in a client with HIV infection is:
- A. Immunosuppression.
- B. Emotional stress.
- C. Unprotected sexual activities.
- D. Contact with saliva.
Correct Answer: A
Rationale: HSV-1 thrives in immunocompromised individuals due to weakened immune defenses.
What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
- A. Observing for confusion
- B. Auscultating breath sounds
- C. Confirming the gag reflex
- D. Measuring blood pressure
Correct Answer: C
Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.
Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse?
- A. Administer oxygen.
- B. Administer bronchodilators.
- C. Administer antianxiety agents.
- D. Use any methods that make the patient more comfortable.
Correct Answer: D
Rationale: Comfort measures tailored to the individual patient’s needs are prioritized in palliative care, ensuring the patient feels supported and comfortable.
Identify the areas of symptom investigation using PQRST that still need to be addressed to provide additional important information (select all that apply).
- A. Timing
- B. Quality
- C. Severity
- D. Palliative
Correct Answer: B
Rationale: The correct answers are 'Timing,' 'Quality,' 'Severity,' and 'Precipitating.' Using the PQRST framework ensures comprehensive evaluation of symptoms. Timing refers to onset and duration; Quality describes the nature of the symptom; Severity quantifies intensity; and Precipitating factors explore triggers.
Which of the following is a therapeutic use of silence?
- A. Encourages a client to use verbal communication.
- B. Facilitates reaching the goals of a client.
- C. Ensures a client’s comprehension before self-care.
- D. Avoids overwhelming a client with new information.
Correct Answer: D
Rationale: Silence prevents information overload, allowing the client time to process and absorb new information effectively.