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: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetics. This intervention helps to reduce nausea and vomiting by blocking the neurotransmitters responsible for triggering these symptoms. Administering antiemetics is the most direct and effective approach to address severe nausea and vomiting post-surgery. Choice B (Placing the client in a supine position) is incorrect because it does not directly address the underlying cause of nausea and vomiting. Choice C (Providing hydration) is important but may not alleviate the symptoms of severe nausea and vomiting. Choice D (Monitoring bowel sounds) is important for assessing gastrointestinal motility but does not directly address the immediate symptoms of nausea and vomiting.

Correct Answer: A

Rationale: The correct answer is A because asking the client to describe the voices can help the nurse assess the situation and understand the client's experience better. This can provide valuable information for the nurse to determine the appropriate intervention or treatment. Leaving the client alone (B) may not address the underlying issue and could potentially worsen the situation. Encouraging the client to talk about the voices (C) is helpful, but asking for a description first allows for a more systematic assessment. Telling the client there are no voices (D) is dismissive and denies the client's reality, which can be harmful and ineffective in providing appropriate care.

Correct Answer: A

Rationale: The correct answer is A because the dull sound over the ribs is a normal finding due to the presence of underlying solid structures such as the liver or spleen. Repositioning the hands or using more force is unnecessary as it won't change the nature of the sound. Referring the patient for additional investigation (choice D) is not warranted as this finding is commonly expected during percussion over the ribs.

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: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (A) is not specific to hip dysplasia. Negative Trendelenburg sign (C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.

Correct Answer: B

Rationale: The correct answer is B: Orientation, as it assesses a person's awareness of time, place, and person. This is crucial for evaluating cognitive functioning in mental health exams. Speech (A) is related to communication, Perception (C) involves interpreting sensory information, and Judgement (D) pertains to decision-making skills. However, in the context of a mental health examination, assessing orientation is essential for understanding a person's cognitive status and ability to interact with their environment effectively.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.