A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of fluid overload?

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: A

Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.

Correct Answer: B

Rationale: The correct answer is B: Administer fluids. Administering fluids is the priority when caring for a client receiving a blood transfusion to prevent circulatory overload. Vital signs (A) should be monitored before and after the transfusion but are not the priority. Monitoring for transfusion reactions (C) is important but comes after administering fluids. Obtaining a blood sample (D) is not a priority during a blood transfusion. Administering fluids ensures adequate hydration and prevents complications during the transfusion process.

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.

Correct Answer: D

Rationale: The correct answer is D: Colace. When a client is immobilized and experiencing constipation, a stool softener like Colace is appropriate to prevent straining and discomfort. Advil and Anasaid are pain relievers, not laxatives. Clinocil is not a recognized medication. Colace is the best choice to address constipation in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the priority action because it ensures the client's safety by preventing injury during the seizure. Placing the client in a safe environment involves removing any objects that could harm them, such as sharp objects or furniture. Positioning on their side (choice A) is important after the seizure to prevent aspiration. Applying warm compresses (choice C) is not indicated during a seizure. Inserting an oral airway (choice D) is not recommended as it can be dangerous during a seizure and should only be done if the client is not breathing after the seizure.

Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and managing weight. This is important for stroke prevention as exercise can improve cardiovascular health and help maintain a healthy weight, reducing the risk of another stroke. Increasing sodium intake (B) can actually elevate blood pressure, increasing stroke risk. Avoiding physical activity (C) can lead to a sedentary lifestyle, which is detrimental to stroke prevention. Consuming high-calorie, high-fat foods (D) can contribute to obesity and other risk factors for stroke. Prioritizing physical activity and weight management aligns with evidence-based guidelines for stroke prevention.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.