A nurse is caring for a patient with a history of heart failure. The nurse should prioritize which of the following interventions?

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Question 1 of 9

A nurse is caring for a patient with a history of heart failure. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Question 2 of 9

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which of the following responses by the nurse is most appropriate?

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and encourages the woman to share her coping mechanisms. This response acknowledges the woman's experience and allows her to express her feelings. It also opens up a dialogue for the nurse to assess her current coping strategies. Choice A is too general and does not prompt further discussion. Choice B is judgmental and dismissive of the woman's experiences. Choice D disregards the woman's emotional state and fails to address her current needs. Overall, Choice C is the most appropriate as it shows empathy, encourages open communication, and allows for further exploration of the woman's coping methods.

Question 3 of 9

A nurse is caring for a patient who is receiving chemotherapy. The nurse should prioritize monitoring for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.

Question 4 of 9

Which type of assessment promotes critical thinking and clustering of similar data?

Correct Answer: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.

Question 5 of 9

What should the nurse do first when a client has a suspected fracture?

Correct Answer: A

Rationale: The correct answer is A: Apply a splint. This is the first step because immobilizing the affected limb helps prevent further injury and reduces pain. Administering fluids (B) and oxygen (C) are important but not the priority in this situation. Elevating the limb (D) can wait until the fracture is stabilized.

Question 6 of 9

Which of the following foods should a client with hypercholesterolemia decrease in their diet?

Correct Answer: B

Rationale: The correct answer is B: Hamburgers. Clients with hypercholesterolemia should decrease their intake of saturated fats and cholesterol. Hamburgers are typically high in saturated fats and cholesterol due to the ground beef patty and cheese. Broiled catfish (A) is a lean protein source and can be a healthier option. Wheat bread (C) is a good source of fiber and can help lower cholesterol levels. Fresh apples (D) are a healthy choice low in saturated fats and cholesterol. Therefore, hamburgers should be decreased in the diet to manage hypercholesterolemia effectively.

Question 7 of 9

A patient is found to have an irregular, jagged scar that is raised and red. The nurse would classify this as:

Correct Answer: B

Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.

Question 8 of 9

A man arrives at the clinic for an annual wellness physical examination. He is not experiencing any acute health problems. Which of the following statements by the nurse is most appropriate when beginning the interview?

Correct Answer: D

Rationale: Step 1: Establish rapport by showing interest in the patient's well-being. Step 2: Emphasize continuity of care by referencing the previous visit. Step 3: Encourage open communication about any changes or concerns. Step 4: Initiate discussion on the patient's health status since the last visit. Summary: A - Too broad and not focused on the patient's own health. B - Assumes the patient has a specific reason for the visit. C - Assumes the patient has hypertension and may not be relevant. D - Encourages discussion on the patient's health status and continuity of care.

Question 9 of 9

Which food is an example of a complete protein?

Correct Answer: B

Rationale: The correct answer is B: Eggs. Eggs are considered a complete protein because they contain all nine essential amino acids required by the body. These amino acids are necessary for various bodily functions, such as muscle growth and repair. Corn (A), peanuts (C), and sunflower seeds (D) are incomplete proteins as they lack one or more essential amino acids. Therefore, eggs are the best choice for a complete protein source compared to the other options provided.

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