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Which intervention is essential when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink water throughout the day
- B. Monitor the client's weight daily to assess fluid balance
- C. Limit fluid intake during meals
- D. Weigh the client once a week to assess fluid balance
Correct Answer: B
Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.
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A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?
- A. How severe is your pain on a scale of 1 to 10?
- B. Where is your pain located?
- C. What medication are you taking for the pain?
- D. When did the pain start?
Correct Answer: B
Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.
What are the potential complications of a patient receiving hemodialysis?
- A. Infection and hypotension
- B. Pulmonary embolism and fluid overload
- C. Blood clot formation and electrolyte imbalance
- D. Low blood pressure and nausea
Correct Answer: A
Rationale: Corrected Question: What are the potential complications of a patient receiving hemodialysis?
Rationale: Infection and hypotension are common complications in patients undergoing hemodialysis. Pulmonary embolism and fluid overload (Choice B) are less common complications associated with hemodialysis. Blood clot formation and electrolyte imbalance (Choice C) are also potential complications but are not as common as infection and hypotension. Low blood pressure and nausea (Choice D) can occur but are not as prevalent as infection and hypotension.
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
- A. Tomatoes
- B. Carrots
- C. Avocados
- D. Apricots
Correct Answer: A
Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.
A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?
- A. Increased heart rate
- B. Persistent cough
- C. Constipation
- D. Sweating
Correct Answer: B
Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.
A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid if you experience gastrointestinal upset.
- B. You should limit your caffeine intake while taking this medication.
- C. This medication may cause your urine to turn dark brown.
- D. You should avoid taking this medication with dairy products.
Correct Answer: D
Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.