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Why is it necessary for a nurse to assess a client’s health beliefs and practices?
- A. For possessing knowledge of health problems affecting a particular cultural group.
- B. For accepting each client as an individual.
- C. For providing culturally competent care to the client.
- D. For viewing the situation from the client’s perspective.
Correct Answer: C
Rationale: Assessing health beliefs ensures personalized, respectful, and effective care aligned with the client's values.
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A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?
- A. Restrict the client's fluid intake.
- B. Assess the client's respiratory status.
- C. Administer diuretics as ordered.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. The first action should be to assess the client's respiratory status as the weight gain could indicate fluid retention leading to pulmonary congestion, a common complication in heart failure. By assessing the respiratory status, the nurse can determine if there are signs of respiratory distress such as increased work of breathing, crackles, or shortness of breath. This assessment will help in identifying any immediate need for interventions such as oxygen therapy or diuretics. Restricting fluid intake (choice A) is important but not the first step. Administering diuretics (choice C) should be based on assessment findings. Notifying the healthcare provider (choice D) can be done after assessing the client's respiratory status.
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:
- A. Pain.
- B. Impaired gas exchange.
- C. Decrease Cardiac output.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Impaired gas exchange is the main issue in pulmonary edema.
You have been pulled to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Calcium
Correct Answer: B
Rationale: Prominent U waves on an ECG strip are typically associated with hypokalemia (low potassium levels). Checking potassium levels is critical to address potential cardiac complications.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.
A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
- A. Avoid eating foods high in vitamin K.
- B. Take aspirin for pain relief.
- C. Report any signs of bruising or bleeding to your healthcare provider.
- D. Limit fluid intake to 2 liters per day.
Correct Answer: C
Rationale: The correct answer is C: Report any signs of bruising or bleeding to your healthcare provider. This instruction is crucial because warfarin can increase the risk of bleeding, especially in clients with a history of gastrointestinal bleeding. Reporting any signs of bruising or bleeding promptly allows for timely intervention to prevent serious complications.
A: Avoiding foods high in vitamin K is not necessary, as consistent intake of vitamin K-containing foods can help maintain stable anticoagulant levels.
B: Taking aspirin along with warfarin can increase the risk of bleeding and should be avoided.
D: Limiting fluid intake is not directly related to the management of warfarin therapy or gastrointestinal bleeding.