Nokea
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria is a classic sign of right-sided heart failure due to fluid redistribution when lying down.
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The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
The nurse is caring for a client with advanced heart failure and cardiomyopathy. The nurse understands that involving nursing, nutritional services, cardiology, and pharmacy in the client's care team is an example of which approach?
- A. peer review
- B. team nursing
- C. multidisciplinary
- D. community nursing
Correct Answer: C
Rationale: A multidisciplinary approach integrates multiple specialties for comprehensive care, as seen with nursing, nutrition, cardiology, and pharmacy.
The client presents to the emergency room with a 'bull's eye' rash. Which question would be most appropriate for the nurse to ask the client?
- A. Have you found any ticks on your body?'
- B. Have you had any nausea in the last 24 hours?'
- C. Have you been outside the country in the last 6 months?'
- D. Have you had any fever for the past few days?'
Correct Answer: A
Rationale: A bull's eye rash is characteristic of Lyme disease, often caused by tick bites, making this the most relevant question.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?
- A. Active
- B. Latent
- C. Transition
- D. Early
Correct Answer: A
Rationale: A cervix dilated to 5 cm with 75% effacement indicates the active phase of labor.