Nokea
What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?
- A. Edema, weight gain, shortness of breath
- B. Fever, cough, chest pain
- C. Increased heart rate, low blood pressure
- D. Increased blood pressure, jugular venous distention
Correct Answer: A
Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.
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A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?
- A. Increase the suction setting on the ventilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.
When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?
- A. Ensure the client has cotton bedding
- B. Keep the oxygen equipment away from heat sources
- C. Use wool blankets to ensure warmth
- D. Allow the client to use electronic devices near the oxygen supply
Correct Answer: B
Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.
Which is the correct method for teaching a client to use a cane when they have left-leg weakness?
- A. Use the cane on the weaker side of the body
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: C
Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.
A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?
- A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
- B. Reinforcing teaching with a client who is learning to walk with a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.
A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Position the drainage bag below the bladder
- B. Wipe the drainage port after emptying
- C. Insert the catheter using sterile technique
- D. Avoid cleansing the urinary meatus
Correct Answer: B
Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.