Nokea
Which of the following nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest.
- B. Administer a prescribed antipyretic.
- C. Elevate the client's head.
- D. Administer supplemental oxygen.
Correct Answer: D
Rationale: Supplemental oxygen addresses hypoxemia, which can reduce tachycardia in clients with myocarditis.
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Clients taking diuretics for chronic congestive heart failure need to be taught to report
- A. 1-lb weight gain in 2 days
- B. Seeing yellow hazes around bright lights
- C. Change in the heart rate
- D. Change in activity tolerance
Correct Answer: A
Rationale: Weight gain indicates fluid retention.
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
- A. Administer vitamin K.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR above the therapeutic range (usually 2-3), like in this case (3.8), administering vitamin K is appropriate to reverse the anticoagulant effects. This helps prevent bleeding complications. Holding the next dose of warfarin (B) may not be sufficient to lower the INR quickly. Increasing the dose of warfarin (C) would further elevate the INR, leading to higher bleeding risk. Notifying the healthcare provider (D) is important, but immediate action with vitamin K is necessary to address the high INR.
What structure separates the left and right sides of the heart?
- A. Interventricular septum
- B. Endocardium
- C. Epicardium
- D. Pericardium
Correct Answer: A
Rationale: The correct answer is A: Interventricular septum. This structure separates the left and right sides of the heart, forming a barrier between the two ventricles. It ensures that oxygenated and deoxygenated blood do not mix within the heart chambers. The endocardium (B) is the inner layer of the heart's chambers, the epicardium (C) is the outer layer of the heart, and the pericardium (D) is the sac surrounding the heart. These structures do not specifically separate the left and right sides of the heart.
Which nursing diagnosis is most appropriate for a patient with chronic venous insufficiency?
- A. Activity Intolerance.
- B. Body Image, disturbed.
- C. Fluid Volume, deficient.
- D. Skin Integrity, impaired.
Correct Answer: D
Rationale: Chronic venous insufficiency increases the risk of skin breakdown, making impaired skin integrity the most relevant diagnosis.
Which condition is characterized by the lungs becoming scarred and stiff, leading to difficulty breathing and inadequate oxygen intake into the bloodstream?
- A. Pulmonary fibrosis
- B. Cystic fibrosis
- C. COPD
- D. Tuberculosis
Correct Answer: A
Rationale: Pulmonary fibrosis is characterized by scarring and stiffening of the lungs, impairing their ability to expand and contract properly for breathing. This leads to difficulty breathing and inadequate oxygen intake into the bloodstream. In contrast, cystic fibrosis primarily affects the respiratory and digestive systems, COPD is a progressive lung disease primarily caused by smoking, and tuberculosis is a bacterial infection that primarily affects the lungs. Therefore, the correct answer is A because it specifically describes the scarring and stiffness of the lungs resulting in breathing difficulties and inadequate oxygen intake.