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When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.
- A. Becoming increasingly short of breath at rest.
- B. Weight gain of 2 lb or more in 1 day.
- C. High intake of sodium for breakfast.
- D. Having to sleep sitting up in a reclining chair.
- E. Weight loss of 2 lb in 1 day.
Correct Answer: A,B,D
Rationale: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.
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A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply.
- A. Avoid lotions containing calamine.
- B. Take baking soda baths.
- C. Keep nails short and clean.
- D. Rub with knuckles instead of nails.
- E. Massage skin with alcohol.
- F. Increase sodium intake in diet.
Correct Answer: B,C,D
Rationale: Baking soda baths (B), short nails (C), and rubbing with knuckles (D) reduce itching and prevent skin breakdown. Calamine (A) is helpful, not avoided. Alcohol (E) dries skin, worsening irritation. Sodium (F) is unrelated.
A client who has a history of mitral valve prolapse tells the nurse that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate?
- A. The physician will need to reevaluate the status of your heart condition before your dental appointment.'
- B. The nurse to remind your dentist that you have a heart condition.'
- C. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections.'
- D. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.'
Correct Answer: D
Rationale: Clients with mitral valve prolapse may require prophylactic antibiotics before dental procedures to prevent infective endocarditis, depending on current guidelines. This is the most appropriate response as it directly addresses the need for preventive measures. The other options either lack specificity or do not address the immediate clinical concern.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
- A. Activity intolerance related to complaints of pain in lower right extremity
- B. Ineffective health maintenance related to lack of knowledge about DVT
- C. Pain related to edema
- D. Risk for impaired skin integrity
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.