A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.

Correct Answer: C

Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.

Correct Answer: B

Rationale: The correct answer is B: culturalism. This is because culturalism refers to the belief that all members of a culture share the same beliefs or practices. Expecting all Chinese persons to believe in the hot-cold theory is an example of culturalism as it assumes a homogenous perspective within the Chinese culture. A: A critical cultural perspective would involve questioning and analyzing cultural beliefs and practices rather than assuming they are universal. C: Ethnic practice refers to specific customs or traditions within a particular ethnic group, not a general belief system like the hot-cold theory. D: Ethnicity refers to one's cultural background or heritage, but it does not address the assumption of shared beliefs within a culture.

Correct Answer: C

Rationale: The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare. A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person. B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult. D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.

Correct Answer: A

Rationale: The correct answer is A: "I will inspect my feet daily for cuts or blisters." This statement indicates proper understanding because daily foot inspection is crucial for early detection of any wounds, which can prevent complications in diabetic patients. Incorrect choices: B: Avoiding trimming toenails can lead to ingrown nails and potential injury. C: Wearing tight shoes can increase the risk of blisters and discomfort. D: Ignoring small wounds can lead to infections and more serious foot issues. In summary, choice A is correct as it promotes proactive foot care, while the other choices can potentially harm the patient's foot health.

Correct Answer: D

Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.

Correct Answer: A

Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications. B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition. C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations. D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.

Correct Answer: A

Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle. Incorrect choices: B: Stopping insulin when blood glucose is normal can lead to dangerous complications. C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach. D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control. In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.

Correct Answer: A

Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.