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Questions 158

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Question 1 of 5

A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

Correct Answer: D

Rationale: Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.

Question 2 of 5

A client with a history of chronic venous insufficiency is admitted with complaints of leg ulcers. The nurse should give priority to:

Correct Answer: A

Rationale: Wound care is critical for leg ulcers in chronic venous insufficiency to promote healing and prevent infection.

Question 3 of 5

A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

Correct Answer: C

Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.

Question 4 of 5

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

Correct Answer: D

Rationale: Radioactive implants emit radiation posing a risk to others. Visitation is limited to short periods (e.g. 30 minutes) to minimize radiation exposure. The other options do not address the safety concern related to radiation.

Question 5 of 5

Which term describes the play activity of the preschool aged child?

Correct Answer: B

Rationale: Preschool-aged children (3–5 years) typically engage in associative play, where they play together with shared activities but without formal rules or organization. Cooperative play develops later, parallel play is common in toddlers, and solitary play is seen in younger children.

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