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Questions 163

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Question 1 of 5

The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

Correct Answer: D

Rationale: Left sided heart failure exhibits signs of pulmonary compromise (SO
B).

Question 2 of 5

The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:

Correct Answer: C

Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect.

Choices A and B are too short, and D is excessively long.

Question 3 of 5

While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:

Correct Answer: C

Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.

Question 4 of 5

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?

Correct Answer: B

Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.

Question 5 of 5

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?

Correct Answer: A

Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.

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