A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. When caring for a client with severe burns, the first priority is to prevent infection, which can be life-threatening. Administering antibiotics helps reduce the risk of infection. Cleansing and dressing the wounds can come after ensuring infection control. Performing a tracheostomy is not typically the first priority unless there are airway concerns. Administering analgesics is important, but it is not the first priority in this case.

Correct Answer: B

Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.

Correct Answer: C

Rationale: Step 1: Nutrition is important for overall health and healing in a client in Buck's traction. Step 2: Elimination is necessary to prevent complications such as constipation. Step 3: Comfort measures help alleviate pain and promote well-being. Step 4: Safety measures ensure the client's well-being during traction. Step 5: ROM exercises are not recommended to prevent displacement of traction. Transportation and isotonic exercises are not directly related to Buck's traction care.

Correct Answer: A

Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: D

Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Correct Answer: C

Rationale: The correct answer is C because stimulation of the sympathetic branch of the autonomic nervous system results in the elevation of the eyelid (ptosis) and dilation of the pupil (mydriasis). This is due to the action of the dilator pupillae muscle and the superior tarsal muscle. Pupillary constriction (choice A) is controlled by the parasympathetic branch via the sphincter pupillae muscle. Adjusting the eye for near vision (choice B) is controlled by the ciliary muscle, which is under parasympathetic control, not sympathetic. Contraction of the ciliary body (choice D) is also controlled by the parasympathetic system for accommodation of near vision, not the sympathetic system.