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Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.
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The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?
- A. "You will be put to sleep before the needle Is inserted."
- B. "The test will take several hours."
- C. "You may fee! a burning sensation when the dye is injected."
- D. "There will be no complications."
Correct Answer: C
Rationale: The correct answer is C: "You may feel a burning sensation when the dye is injected." This is important preprocedure teaching for carotid angiography because it prepares the patient for a common sensation during the procedure, helping to manage their expectations and reduce anxiety. This information is crucial for informed consent.
Choice A is incorrect because carotid angiography is usually done under local anesthesia, not general anesthesia. Choice B is incorrect as carotid angiography typically takes about 1-2 hours, not several hours. Choice D is incorrect because all medical procedures, including carotid angiography, carry potential risks and complications, which should be discussed with the patient.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term.
Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues.
Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels.
Step 4: Emergency numbers are important but secondary to long-term management.
Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.
The nurse needs to administer an IM injection of 2.4 million units of penicillin G. it is supplied in a vial of 5,000,000 units of powder for injection. Instructions state to dilute with 8 mL of sterile water. How manu mL should the nurse draw up?
- A. 2.6 mL
- B. 4.1 mL
- C. 3.8 mL
- D. 4.4 mL
Correct Answer: C
Rationale: The correct answer is C: 3.8 mL. To calculate the volume needed, first determine the concentration of the solution after reconstitution: 2.4 million units / 5,000,000 units = 0.48. Next, divide the desired dose by the concentration: 2.4 million units / 0.48 = 5 mL. Since the instructions state to dilute with 8 mL of sterile water, the total volume will be 13 mL. To find the volume of the powder to draw up, subtract the water volume from the total volume: 13 mL - 8 mL = 5 mL. Therefore, the nurse should draw up 5 mL of the reconstituted solution, which is equivalent to 3.8 mL of powder for injection.
Incorrect choices: A, B, and D are incorrect because they do not consider the dilution factor of adding sterile water to the powder for injection. Option A is less than the
Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:
- A. Cell division or mitosis during the M phase of the cell cycle.
- B. Normal cellular processes during the S phase of the cell cycle.
- C. The chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle-nonspecific).
- D. One or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle- nonspecific).
Correct Answer: D
Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Check the area after the next menstrual
- C. Squeeze the nipple to check for period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.