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Which teaching point should the nurse include for a client with heart failure?
- A. Avoid all physical activity.
- B. Report weight gain of 2 pounds or more in a day.
- C. Take extra diuretics if you feel short of breath.
- D. Eat high-sodium foods to maintain electrolytes.
Correct Answer: B
Rationale: Rapid weight gain indicates fluid retention, requiring prompt reporting to manage heart failure.
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The nurse is assessing a client with dilated cardiomyopathy. Which finding is expected?
- A. Jugular vein distension
- B. Hypertension
- C. Dry skin
- D. Tachypnea
Correct Answer: A
Rationale: Dilated cardiomyopathy causes reduced cardiac output, leading to jugular vein distension from fluid backup.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my successful,' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
The client diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.
The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client?
- A. Occupational therapist.
- B. Social worker.
- C. Physical therapist.
- D. Cardiac rehabilitation.
Correct Answer: B
Rationale: A social worker (B) coordinates home care for an elderly client with a chronic ulcer. OT (A) and PT (C) are less relevant, and cardiac rehab (D) is unrelated.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.