A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Has his weight changed in the last several days? The nurse should obtain information about the client's weight changes because in heart failure, sudden weight gain can be indicative of fluid retention, a common symptom of worsening HF. Monitoring weight is crucial in managing HF as it helps in assessing fluid status and adjusting medications accordingly to prevent exacerbations. Option A) What time did he take his last medications? While medication adherence is important, in this case, the client's symptom is more indicative of fluid retention rather than medication timing. Option C) Is he still able to tighten his belt buckle? This option is not directly related to the symptom of tight shoes and does not provide relevant information about the client's current condition. Option D) How many hours did he sleep last night? While sleep is important, it is not the priority in this situation where the client is experiencing symptoms of possible fluid retention. Educationally, this question highlights the importance of recognizing and assessing symptoms of heart failure exacerbation, emphasizing the significance of monitoring weight changes in HF patients as part of their ongoing care and management.

Correct Answer: B

Rationale: In this scenario, the correct intervention is to prepare the client to return to the operating room (Option B). When a wound dehiscence occurs with evisceration, it is a surgical emergency that requires immediate intervention to prevent further complications such as infection, further tissue damage, or potential sepsis. Returning the client to the operating room allows for proper assessment, wound closure, and management by the surgical team. Option A (Bring additional sterile dressing supplies to the room) is incorrect because just applying more dressings without addressing the underlying surgical emergency is inadequate and may delay appropriate treatment. Option C (Obtain a sample of the drainage to send to the lab) is also incorrect as it focuses on collecting a sample rather than addressing the immediate surgical issue. Option D (Auscultate the abdomen for bowel sound activity) is not the priority in this critical situation where prompt surgical intervention is required. From an educational perspective, this scenario highlights the importance of recognizing and responding to postoperative complications promptly in a healthcare setting. Nurses need to be trained to identify surgical emergencies like wound dehiscence and evisceration and understand the appropriate steps to take to ensure patient safety and optimal outcomes. This case underscores the critical nature of surgical wound care and the necessity of immediate action when faced with such complications in a clinical setting.

Correct Answer: A

Rationale: In the context of a client with Cushing's syndrome recovering from surgery, the immediate intervention warranted by the nurse is an irregular apical pulse, which is the correct answer (Option A). Cushing's syndrome is characterized by excess cortisol levels, which can lead to cardiovascular complications such as hypertension, fluid retention, and electrolyte imbalances. An irregular apical pulse could indicate cardiac arrhythmias or other cardiovascular issues that require prompt attention to prevent further complications or deterioration. Option B, purple marks on the skin of the abdomen (Cushing's striae), while associated with Cushing's syndrome, are not typically urgent or indicative of immediate complications post-surgery. Option C, a quarter-size blood spot on the dressing, may indicate some bleeding but is not as critical as a cardiac issue in this scenario. Option D, pitting ankle edema, is a common finding in both Cushing's syndrome and postoperative patients due to fluid retention, but it is not as urgent as addressing a potential cardiac problem. Educationally, understanding the specific manifestations of Cushing's syndrome, the postoperative care considerations for this population, and the prioritization of assessments based on potential complications are crucial for nurses caring for these patients. Recognizing the significance of cardiovascular assessments in high-risk patients like those with Cushing's syndrome can help prevent adverse events and promote better outcomes.

Correct Answer: C

Rationale: The most important instruction for the nurse to provide to the female client being discharged with an indwelling urinary catheter after bladder surgery is option C: Keep the drainage bag lower than the level of the bladder. Rationale: - Keeping the drainage bag lower than the bladder ensures a continuous flow of urine from the bladder to the bag, preventing backflow of urine or infections. - If the drainage bag is positioned above the level of the bladder, urine can flow back into the bladder, increasing the risk of urinary tract infections and compromising the surgical repair. Why the other options are incorrect: - Option A: Avoid coiling the tubing and keep it free of kinks is important but not as critical as preventing backflow of urine. - Option B: Cleansing the perineal area with soap and water twice daily is good hygiene practice but does not directly impact the function of the catheter. - Option D: Drinking 1,000 ml of fluids daily to irrigate the catheter is not necessary as the catheter is designed to drain urine effectively without additional irrigation. Educational context: Understanding proper care of indwelling urinary catheters is crucial for nurses caring for patients post-surgery. Teaching patients correct catheter care helps prevent complications and promotes optimal recovery. By emphasizing the importance of keeping the drainage bag below the level of the bladder, nurses can ensure patient safety and reduce the risk of post-operative infections.

Correct Answer: B

Rationale: In the context of a client diagnosed with open-angle glaucoma, the priority nursing diagnosis of "visual sensory/perceptual alterations" is based on the etiology of decreased peripheral vision. This is the correct answer (B) because in open-angle glaucoma, there is a gradual increase in intraocular pressure leading to optic nerve damage. This damage initially affects the peripheral vision before progressing to central vision loss. Therefore, addressing the alteration in peripheral vision is crucial in the care of a client with glaucoma to prevent further visual impairment. Limited eye movement (A) is not the primary etiology for the nursing diagnosis in this case, as glaucoma primarily affects vision due to increased intraocular pressure rather than eye movement restrictions. Blurred distance vision (C) is a common symptom in various eye conditions but is not specific to open-angle glaucoma. Photosensitivity (D) is also not directly related to the etiology of visual sensory alterations in glaucoma. Educationally, understanding the pathophysiology of open-angle glaucoma and its impact on visual function is essential for nurses caring for clients with this condition. Recognizing the priority nursing diagnosis based on the specific etiology of the disease helps in providing targeted and effective care to prevent further vision loss and promote optimal visual health in these clients.