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What is the best method to manage fluid overload in a patient with heart failure?
- A. Administer diuretics
- B. Provide oral fluids
- C. Increase fluid intake
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.
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A nurse is assessing a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings requires immediate intervention?
- A. Aspirating 100 mL of gastric residual
- B. Gastric pH of 4
- C. Auscultating crackles in the lung bases
- D. Checking residual every 6 hours
Correct Answer: C
Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.
A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?
- A. Carrots
- B. Broccoli
- C. Chicken
- D. Bananas
Correct Answer: B
Rationale: The correct answer is B: Broccoli. Broccoli is rich in calcium and is a suitable food to recommend to clients with osteoporosis to increase their calcium intake. Carrots, chicken, and bananas are not as high in calcium content compared to broccoli and therefore not the most appropriate choices for increasing calcium intake in clients with osteoporosis.
A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Apply a moisture barrier ointment.
Correct Answer: D
Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.
How should a healthcare professional handle a patient who is refusing to take a prescribed medication?
- A. Immediately give the medication
- B. Assess the reasons for refusal
- C. Document refusal
- D. Explore alternative treatment options
Correct Answer: B
Rationale: Assessing the reasons for refusal is crucial as it allows the healthcare professional to understand the patient's concerns, which can range from fear of side effects to cost issues. By identifying the underlying reasons, the healthcare professional can tailor their approach to address these specific concerns, potentially improving medication adherence. Giving the medication immediately (Choice A) without understanding the patient's reasons for refusal can lead to further non-compliance. While documenting refusal (Choice C) is important for legal and tracking purposes, it does not directly address the patient's concerns. Exploring alternative treatment options (Choice D) may be considered after understanding the reasons for refusal, but it is not the initial step in managing medication refusal.
Which lab value should be monitored in a patient on digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor digoxin levels
- D. Monitor sodium levels
Correct Answer: C
Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.