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.

Correct Answer: D

Rationale: The correct answer is D: Morton's neuroma. This condition typically presents as a mass in the foot causing pain and difficulty walking. The nurse should document it as Morton's neuroma because it specifically refers to a benign growth of nerve tissue between the toes. Plantar fasciitis (A) is inflammation of the tissue on the bottom of the foot, not a mass. Hallux valgus (B) is a bunion deformity of the big toe joint. Hammertoe (C) is a deformity of the toe joints. Therefore, the correct choice is D as it aligns with the description of a mass causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. The first step in managing an asthma attack is to address the underlying cause, which is airway constriction. Bronchodilators help relax the muscles around the airways, making it easier for the client to breathe. Providing oxygen therapy (B) can be helpful but addressing airway constriction is the priority. Administering analgesics (C) or pain medication (D) is not appropriate as asthma attacks are not typically associated with pain.

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.

Correct Answer: A

Rationale: Step 1: Respect and compassion are essential in end-of-life care to support patients emotionally. Step 2: Nurses need to show empathy and understanding towards patients and their families. Step 3: Providing comfort and dignity in the final stages of life is crucial. Step 4: Assessing and intervening (Choice B) is important but not the primary competency in end-of-life care. Step 5: Setting goals and dynamic changes to care (Choice C) may be relevant but not as fundamental as respect and compassion. Step 6: Keeping sad news away (Choice D) goes against transparency and trust-building in end-of-life care.

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue by taking X-ray images. Tumors can be cancerous or benign, making early detection crucial for treatment. Pain (A) is a symptom, not detected by mammography. Edema (C) is swelling caused by fluid retention, not a primary target of mammography. Epilepsy (D) is a neurological disorder, unrelated to mammography's purpose. Therefore, the correct answer is B.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.

Correct Answer: C

Rationale: The correct answer is C: small intestine. This is because the small intestine is where the majority of nutrient absorption takes place due to its large surface area and presence of villi for absorption. The stomach (A) primarily functions in digestion, not absorption. The pancreas (B) produces digestive enzymes but does not directly absorb nutrients. The gallbladder (D) stores bile produced by the liver to aid in digestion but does not participate in absorption directly.