Heart failure
A nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?
A. Jugular venous distention (JVD).
B. Dependent edema in the lower extremities.
C. Weight gain of 5 pounds in 48 hours.
D. Hepatomegaly with tenderness upon palpation.
Correct Answer: C. Weight gain of 5 pounds in 48 hours.
Rationale: A rapid weight gain of 5 pounds in 48 hours indicates significant fluid retention, requiring immediate intervention to prevent further complications like pulmonary edema or worsening heart failure.
A nurse is caring for a patient with a femur fracture in skeletal traction. The patient reports sudden chest pain and shortness of breath. Which complication should the nurse suspect?
A. Fat embolism syndrome (FES)
B. Compartment syndrome
C. Pulmonary embolism (PE)
D. Deep vein thrombosis (DVT)
Correct Answer: A. Fat embolism syndrome (FES)
Rationale: Fat embolism syndrome often occurs in long bone fractures like a femur. Sudden chest pain and shortness of breath are hallmark signs, sometimes accompanied by petechiae.
A nurse is caring for a patient with COPD who is on oxygen therapy. The patient is confused, and their respiratory rate is 40 breaths per minute. The nurse notes that the patient's oxygen saturation is 88%. Which of the following is the nurse's priority intervention?
A) Increase the oxygen flow rate to 4 L/min
B) Administer a short-acting bronchodilator as prescribed
C) Encourage the patient to take deep, slow breaths
D) Notify the healthcare provider immediately for further evaluation
Answer: B) Administer a short-acting bronchodilator as prescribed
Rationale: In a patient with COPD, an increased respiratory rate and confusion may indicate an exacerbation. A bronchodilator will help open the airways, reduce the work of breathing, and improve oxygenation, which is the priority in this scenario.
A patient with a urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). Which instruction should the nurse include when teaching the patient about this medication?
A. This medication will treat your infection.
B. Take this medication only at bedtime.
C. Your urine may turn reddish-orange while taking this medication.
D. This medication must be taken on an empty stomach.
Correct Answer: C. Your urine may turn reddish-orange while taking this medication.
Rationale: Phenazopyridine is a urinary analgesic that commonly causes reddish-orange urine discoloration, which is harmless but can be alarming if the patient is unaware.
A client with Crohn’s disease presents with weight loss and diarrhea despite dietary modifications. Which complication should the nurse prioritize assessing for?
A. Intestinal stricture
B. Malabsorption syndrome
C. Electrolyte imbalance
D. Bowel perforation
Answer: C. Electrolyte imbalance
Rationale: Electrolyte imbalance is a priority due to frequent diarrhea and weight loss, which can lead to dehydration and significant metabolic disruptions. Immediate recognition and intervention are critical.
A client with chronic heart failure is prescribed metoprolol. During a follow-up visit, the client reports fatigue and dizziness. What is the nurse's priority action?
A. Discontinue the medication and notify the provider.
B. Assess the client's blood pressure and heart rate.
C. Educate the client that fatigue is an expected side effect.
D. Encourage the client to increase fluid intake.
Correct Answer: B. Assess the client's blood pressure and heart rate.
Rationale: Fatigue and dizziness are potential side effects of beta-blockers like metoprolol, often related to hypotension or bradycardia. Assessing vital signs is the priority before deciding on further actions.
A nurse is assessing a patient with osteomyelitis who reports severe pain unrelieved by medications. The affected area is swollen and warm. Which action should the nurse prioritize?
A. Apply a cold compress to the affected area
B. Elevate the limb to reduce swelling
C. Notify the healthcare provider immediately
D. Document the findings and reassess them in 30 minutes
Correct Answer: C. Notify the healthcare provider immediately
Rationale: Severe pain unrelieved by medications may indicate worsening osteomyelitis or potential progression to a bone abscess. Immediate reporting is critical to modify treatment.
A nurse is caring for a patient with pneumonia. The patient is receiving antibiotic therapy and has an elevated white blood cell count. Which of the following would be of greatest concern for the nurse in assessing this patient’s response to treatment?
A) Decreased temperature
B) Increased oxygen saturation
C) Increased respiratory rate
D) Decreased white blood cell count
Answer: C) Increased respiratory rate
Rationale: An increased respiratory rate indicates respiratory distress or worsening hypoxia, which would be concerning despite antibiotic therapy. It suggests that the patient's pneumonia may not be improving, or a complication may be developing.
The nurse is educating a patient with recurrent UTIs about prevention. Which statement by the patient indicates the need for further teaching?
A. I will drink at least 2 liters of water each day.
B. I’ll void after sexual activity to flush out bacteria.
C. Taking bubble baths will help soothe my urinary tract.
D. I’ll wipe from front to back after using the toilet.
Correct Answer: C. Taking bubble baths will help soothe my urinary tract.
Rationale: Bubble baths can irritate the urethra and increase the risk of UTIs. Patients prone to UTIs should avoid bubble baths.
The nurse is caring for a client post-colectomy with a new ileostomy. The client reports minimal stoma output 24 hours after surgery. What is the nurse's next action?
A. Notify the healthcare provider immediately.
B. Encourage the client to increase oral fluid intake.
C. Assess the stoma for edema and discoloration.
D. Document the finding as normal for this stage.
Answer: C. Assess the stoma for edema and discoloration
Rationale: A stoma with minimal output after surgery could indicate edema or ischemia, which requires prompt assessment. Early identification can prevent complications such as necrosis.
A client with heart failure reports dyspnea at rest and frothy, blood-tinged sputum. What is the nurse’s priority intervention?
A. Notify the healthcare provider immediately.
B. Administer furosemide IV as prescribed.
C. Position the client in a high Fowler’s position.
D. Initiate continuous cardiac monitoring.
Correct Answer: C. Position the client in high Fowler’s position.
Rationale: Dyspnea and frothy, blood-tinged sputum indicate pulmonary edema, requiring immediate positioning in high Fowler’s to facilitate breathing and reduce pulmonary congestion.
A patient with a recent total hip replacement reports hearing a "popping" sound in the hip, followed by severe pain and inability to move the leg. What should the nurse do first?
A. Perform a neurovascular assessment of the affected leg
B. Administer prescribed pain medication
C. Notify the healthcare provider immediately
D. Immobilize the leg in the current position
Correct Answer: C. Notify the healthcare provider immediately
Rationale: A "popping" sound, severe pain, and immobility suggest possible hip dislocation, a surgical emergency requiring immediate attention.
A nurse is preparing to discharge a patient with active tuberculosis (TB). Which statement by the patient indicates the need for further teaching?
A) "I should continue taking my medications for the entire prescribed duration, even if I feel better."
B) "I will avoid close contact with people for the first two weeks of my treatment."
C) "I need to notify public health officials about my diagnosis."
D) "I can stop wearing a mask once I start feeling better."
Answer: D) "I can stop wearing a mask once I start feeling better."
Rationale: The patient must continue wearing a mask and take precautions until they are no longer infectious, even if they begin to feel better. TB is highly contagious, and precautions should be maintained until a healthcare provider confirms the patient is no longer contagious.
A patient with chronic kidney disease (CKD) has a potassium level of 6.5 mEq/L. Which intervention should the nurse perform first?
A. Administer sodium polystyrene sulfonate (Kayexalate) as prescribed.
B. Place the patient on a cardiac monitor.
C. Prepare the patient for hemodialysis.
D. Restrict potassium-containing foods immediately.
Correct Answer: B. Place the patient on a cardiac monitor.
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias. The nurse should immediately initiate cardiac monitoring to detect changes in heart rhythm.
A client with a recent Billroth II procedure reports dizziness, tachycardia, and abdominal cramping 30 minutes after meals. Which nursing action is most appropriate?
A. Administer a prescribed antiemetic.
B. Encourage the client to ambulate immediately after eating.
C. Recommend lying down after meals.
D. Increase the client's intake of high-carbohydrate foods.
Correct Answer: C
Rationale: The client is experiencing dumping syndrome. Encouraging the client to lie down after meals slows gastric emptying and helps prevent symptoms.
A client with heart failure is prescribed digoxin. The nurse finds that the client’s heart rate is 56 beats per minute and they report nausea and blurred vision. What is the nurse's best action?
A. Administer the digoxin as prescribed and monitor for worsening symptoms.
B. Hold the medication and notify the healthcare provider immediately.
C. Administer an antiemetic for nausea and reassess in one hour.
D. Check the client’s potassium level before making any decisions.
Correct Answer: B. Hold the medication and notify the healthcare provider immediately.
Rationale: The client’s symptoms (bradycardia, nausea, blurred vision) suggest digoxin toxicity. The nurse should hold the medication and notify the provider for further management.
A patient with an external fixation device for a tibial fracture reports severe pain at the pin sites and notices increased redness and purulent drainage. The nurse observes that the skin around the pins is warm and swollen. What is the nurse’s first action?
A. Clean the pin sites with an antiseptic solution per protocol
B. Administer prescribed pain medication for relief
C. Apply a warm compress to reduce inflammation
D. Assess the patient’s temperature and vital signs
Correct Answer: A. Clean the pin sites with an antiseptic solution per protocol
Rationale: Severe pain, redness, swelling, and purulent drainage at pin sites suggest a local infection. Cleaning the pin sites with an antiseptic solution is the nurse’s first intervention to address potential infection and prevent its progression. Pin site care is a critical component of external fixation management.
A nurse is assessing a patient with COPD who is showing signs of respiratory failure. Which of the following assessment findings is most indicative of impending respiratory arrest?
A) The patient has a respiratory rate of 30 breaths per minute and a pulse rate of 110 bpm.
B) The patient has absent breath sounds on the left side and a cough with thick yellow sputum.
C) The patient is using accessory muscles to breathe, with a respiratory rate of 45 breaths per minute.
D) The patient is lethargic, has decreased breath sounds, and has a PaCO2 level of 55 mmHg.
Answer: D) The patient is lethargic, has decreased breath sounds, and has a PaCO2 level of 55 mmHg.
Rationale: Lethargy, decreased breath sounds, and elevated PaCO2 (hypercapnia) indicate worsening respiratory failure and are signs that the patient may be approaching respiratory arrest. Elevated PaCO2 levels suggest that the patient is unable to effectively eliminate carbon dioxide, a critical sign of impending respiratory collapse.
A patient with a Foley catheter develops cloudy urine and fever. The nurse suspects a catheter-associated urinary tract infection (CAUTI). Which intervention should the nurse implement first?
A. Administer the prescribed antibiotic.
B. Replace the Foley catheter using a sterile technique.
C. Obtain a urine specimen from the catheter port for culture.
D. Increase the patient’s oral fluid intake to flush bacteria from the bladder.
Correct Answer: C. Obtain a urine specimen from the catheter port for culture.
Rationale: A urine specimen should be collected first to identify the causative organism before starting antibiotics. This ensures that the treatment is targeted and effective.
The nurse is educating a client with peptic ulcer disease about avoiding complications such as hemorrhage and perforation. Which instructions should the nurse include? (Select all that apply.)
A. Avoid NSAIDs and aspirin.
B. Take prescribed medications regularly, including proton pump inhibitors.
C. Reduce stress by engaging in relaxation techniques.
D. Avoid drinking water with meals.
E. Report symptoms of black, tarry stools or vomiting blood immediately.
F. Consume small, frequent meals to avoid overloading the stomach.
Correct Answers: A, B, C, E
Rationale:
A. NSAIDs and aspirin can cause gastric mucosal damage, increasing the risk of bleeding and perforation.
B. Regular use of proton pump inhibitors or H2-receptor antagonists reduces acid production and helps prevent ulcer complications.
C. Stress management reduces gastric acid secretion, lowering the risk of exacerbating ulcers.
E. Black, tarry stools or hematemesis indicate potential GI bleeding, a serious complication requiring immediate intervention.
A nurse is completing the admission assessment of a client with acute decompensated heart failure and pulmonary edema. Which findings should the nurse anticipate? (Select all that apply).
A. Pink, frothy sputum
B. Jugular venous distention
C. Crackles in the lung fields
D. Increased urine output
E. Tachycardia
F. Peripheral cyanosis
Correct Answers: A, B, C, E, F
Rationale:
A nurse is caring for a patient with osteomyelitis. Which interventions are appropriate to include in the care plan? (Select all that apply)
A. Administer intravenous antibiotics as prescribed
B. Encourage weight-bearing exercises to promote healing
C. Perform sterile dressing changes on the affected area
D. Monitor the patient’s white blood cell (WBC) count regularly
E. Elevate the affected limb to reduce swelling
F. Apply cold compresses to the affected limb
Correct Answers: A, C, D, E
Rationale:
A nurse is educating a group of patients with asthma about managing exacerbations. Which of the following actions should the nurse include as part of asthma management? (Select all that apply)
A) "Use a short-acting bronchodilator at the onset of symptoms."
B) "Increase the dose of your corticosteroid inhaler during an asthma attack."
C) "Monitor your peak flow rate regularly, even when you feel well."
D) "If your symptoms improve, stop using your medications."
E) "Avoid triggers, such as smoke, dust, and allergens, to prevent asthma attacks."
Answer:
A) "Use a short-acting bronchodilator at the onset of symptoms."
B) "Increase the dose of your corticosteroid inhaler during an asthma attack."
C) "Monitor your peak flow rate regularly, even when you feel well."
E) "Avoid triggers, such as smoke, dust, and allergens, to prevent asthma attacks."
Rationale:
The nurse is caring for a patient with chronic kidney disease (CKD) who is at risk for complications related to fluid overload. Which interventions should the nurse implement? (Select all that apply.)
A. Monitor daily weights.
B. Encourage a high-protein diet.
C. Assess for jugular vein distention.
D. Restrict sodium intake.
E. Administer diuretics as prescribed.
Correct Answers: A, C, D, E
Rationale:
The nurse is preparing a care plan for a client with peritonitis. Which interventions should the nurse include? (select all that apply).
A. Administer IV antibiotics as prescribed.
B. Encourage oral fluid intake to maintain hydration.
C. Maintain the client in a semi-Fowler's position.
D. Assess for signs of sepsis, such as fever or altered mental status.
E. Provide a high-fiber diet to stimulate bowel motility.
F. Monitor strict intake and output for signs of fluid imbalance.
Answer: A, C, D, F
Rationale:
A. Administer IV antibiotics as prescribed: Peritonitis often results from bacterial infection, making antibiotic therapy essential to treatment.
C. Maintain the client in a semi-Fowler's position: This promotes drainage of peritoneal fluid and reduces the risk of respiratory complications.
D. Assess for signs of sepsis, such as fever or altered mental status: Sepsis is a life-threatening complication of peritonitis, requiring close monitoring.
F. Monitor strict intake and output for signs of fluid imbalance: Fluid shifts in peritonitis can lead to hypovolemia, so monitoring I&O is critical.