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A nurse is caring for a client with a diagnosis of heart failure. Which of the following symptoms would the nurse expect to observe in this client?
- A. Bradycardia
- B. Hypotension
- C. Crackles in the lungs
- D. Decreased urine output
Answer: C. Crackles in the lungs
Explanation: Heart failure is a condition in which the heart is unable to pump blood effectively, leading to fluid accumulation in the lungs and other body tissues. Crackles in the lungs are a sign of fluid accumulation, which is a common symptom of heart failure. Bradycardia and hypotension may be present in some cases, but they are not specific to heart failure. Decreased urine output may be a sign of worsening heart failure, but it is not the most specific symptom.
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A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take first?
- A. Assess the client's vital signs
- B. Verify the client's blood type
- C. Obtain informed consent
- D. Prime the blood tubing
Answer: C. Obtain informed consent
Explanation: Before administering a blood transfusion, the nurse must first obtain informed consent from the client. This ensures that the client understands the risks and benefits of the procedure and agrees to proceed. Assessing vital signs, verifying blood type, and priming the tubing are all important steps in the process, but obtaining informed consent is the priority.
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A nurse is caring for a client who has just undergone a total hip replacement. Which of the following interventions should the nurse implement to prevent complications?
- A. Encourage the client to ambulate frequently
- B. Maintain the client in a supine position
- C. Apply a heating pad to the surgical site
- D. Administer prophylactic antibiotics
Answer: A. Encourage the client to ambulate frequently
Explanation: Early ambulation is important after a total hip replacement to prevent complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. Maintaining the client in a supine position and applying a heating pad to the surgical site are not appropriate interventions. Administering prophylactic antibiotics may be done as ordered by the healthcare provider, but encouraging ambulation is the priority intervention.
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A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). Which of the following oxygen delivery devices would be most appropriate for this client?
- A. Non-rebreather mask
- B. Venturi mask
- C. Nasal cannula
- D. Simple face mask
Answer: B. Venturi mask
Explanation: A Venturi mask is the most appropriate oxygen delivery device for a client with COPD because it delivers a precise concentration of oxygen, which is important for clients with chronic lung diseases. Non-rebreather masks, nasal cannulas, and simple face masks do not provide the same level of precision in oxygen delivery.
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A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Albuterol
- B. Prednisone
- C. Montelukast
- D. Ipratropium
Answer: A. Albuterol
Explanation: Albuterol is a short-acting beta-agonist that provides rapid relief of bronchospasm during an acute asthma attack. Prednisone, montelukast, and ipratropium are all used in the management of asthma, but they do not provide the immediate relief that albuterol does.
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A nurse is caring for a client who has been diagnosed with a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?
- A. Apply a heating pad to the affected extremity
- B. Encourage the client to ambulate frequently
- C. Elevate the affected extremity
- D. Massage the affected extremity
Answer: C. Elevate the affected extremity
Explanation: Elevating the affected extremity can help reduce swelling and improve blood flow in a client with a DVT. Applying a heating pad and massaging the affected extremity are contraindicated, as they can increase the risk of dislodging the clot. Ambulation may be encouraged once the client is on appropriate anticoagulant therapy and the healthcare provider has deemed it safe.
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A nurse is caring for a client who has just been diagnosed with type 2 diabetes. Which of the following statements by the client indicates a need for further teaching?
- A. "I should check my blood sugar levels regularly."
- B. "I can still eat carbohydrates, but I need to monitor my intake."
- C. "I should exercise regularly to help control my blood sugar."
- D. "I don't need to take any medications because I can control my diabetes with diet alone."
Answer: D. "I don't need to take any medications because I can control my diabetes with diet alone."
Explanation: While diet and exercise are important components of managing type 2 diabetes, many clients also require medications to help control their blood sugar levels. The other statements by the client indicate an understanding of the importance of blood sugar monitoring, carbohydrate intake, and exercise.
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A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central venous catheter. Which of the following interventions should the nurse implement to prevent complications?
- A. Change the TPN solution every 12 hours
- B. Monitor blood glucose levels regularly
- C. Administer the TPN solution at room temperature
- D. Use a 5-micron filter when administering the TPN solution
Answer: B. Monitor blood glucose levels regularly
Explanation: Monitoring blood glucose levels regularly is important for clients receiving TPN, as the high glucose content of the solution can cause hyperglycemia. Changing the TPN solution every 12 hours is not necessary, and administering the solution at room temperature can increase the risk of bacterial growth. A 0.22-micron filter, not a 5-micron filter, should be used when administering TPN.
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A nurse is caring for a client who has just been diagnosed with tuberculosis. Which of the following medications should the nurse anticipate administering as part of the client's treatment regimen?
- A. Amoxicillin
- B. Ciprofloxacin
- C. Isoniazid
- D. Vancomycin
Answer: C. Isoniazid
Explanation: Isoniazid is a first-line medication used in the treatment of tuberculosis. Amoxicillin, ciprofloxacin, and vancomycin are antibiotics used to treat other types of bacterial infections, but they are not typically used in the treatment of tuberculosis.
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A nurse is caring for a client who is experiencing severe pain following surgery. Which of the following pain management techniques should the nurse implement?
- A. Administer pain medication as needed
- B. Encourage the use of relaxation techniques
- C. Administer pain medication on a fixed schedule
- D. Encourage the client to use distraction techniques
Answer: C. Administer pain medication on a fixed schedule
Explanation: Administering pain medication on a fixed schedule is the most effective way to manage severe pain following surgery, as it helps to maintain a consistent level of pain relief. Administering pain medication as needed and encouraging the use of relaxation and distraction techniques may be helpful for managing mild to moderate pain, but they are not as effective for severe pain.
