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Questions 158

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Question 1 of 5

During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

Correct Answer: C

Rationale: Any movement of the joint causes severe pain.
Touching or moving the joint causes severe pain. Immobilization in a functional position allows the joint to rest and heal. Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.

Question 2 of 5

The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:

Correct Answer: A

Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.

Question 3 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.

Question 4 of 5

The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:

Correct Answer: C

Rationale: These therapies aim to dilate airways (aerosols), mobilize mucus (percussion), and clear secretions (postural drainage) to improve breathing in cystic fibrosis.

Question 5 of 5

The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:

Correct Answer: A

Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.

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