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Questions 164

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Question 1 of 5

An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?

Correct Answer: D

Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.

Question 2 of 5

The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:

Correct Answer: A

Rationale: Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death.

Question 3 of 5

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?

Correct Answer: D

Rationale: Massaging the leg (
D) risks dislodging the clot, causing embolism, requiring immediate intervention. Ambulation (
A), warm compresses (
B), and elevation (
C) are appropriate.

Question 4 of 5

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?

Correct Answer: D

Rationale: Delaying 911 after three doses (
D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (
A), lying down (
B), and not swallowing (
C) are correct.

Question 5 of 5

What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

Correct Answer: A

Rationale: Maintaining and preserving function. Preserving joint function is critical for quality of life in arthritis.

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