Which of the following positions would best aid breathing for a patient with acute pulmonary edema?
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Solution
High Fowler’s position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the heart’s workload.
Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking?
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Solution
The initial priority is to decrease oxygen consumption by sitting the patient down.
Options B, C, and D: Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patient’s condition is stabilized, he can be returned to bed.
In which of the following types of cardiomyopathy does cardiac output remain normal?
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Solution
Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged.
Options A, C, and D: Dilated cardiomyopathy, obliterative cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output.
Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?
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Solution
Lower back pain results from expansion of an aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back.
Option A: Abdominal pain is the most common symptom resulting from impaired circulation.
Option B: Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease.
Option C: Chest pain usually is associated with coronary artery or pulmonary disease.
What’s the first intervention for a patient experiencing chest pain and an p02 of 89%?
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Solution
Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage.
Options A and C: Sublingual nitroglycerin and morphine are commonly administered after oxygen.
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
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Solution
Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles.
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
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Solution
The client who has recently had a thyroidectomy is at risk for tracheal edema.
Option B: padded tongue blade is used for seizures and not for the client with tracheal edema.
Options C and D: If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem.
Which task should be assigned to the nursing assistant?
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Solution
Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia.
Option A: Only an RN or the physician can place the client in seclusion.
Option B: The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable.
Option D: A nurse or physical therapist should ambulate the client with a fractured hip.
A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
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Solution
Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow.
Options A and C: Douching is not recommended and obtaining a urinalysis monthly is not necessary.
Option D: The client should practice wiping from front to back after voiding and bowel movements.
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
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Solution
Option A: Valium is not given in the same syringe with other medications.
Option C: it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.
Option D: These medications can be given to the same client.