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: 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: C

Rationale: The correct answer is C because stopping the inhaler once feeling better is incorrect. Inhalers are used to manage COPD symptoms long-term, not just when feeling unwell. Step 1: Explain that inhalers are essential for managing COPD and should be used consistently. Step 2: Emphasize that stopping inhaler use prematurely can lead to exacerbation of symptoms and worsening of the condition. Step 3: Reinforce the importance of following the prescribed treatment plan for optimal COPD management. Other choices are incorrect: A: True, avoiding second-hand smoke is crucial for COPD management. B: True, taking medications as prescribed is essential. D: True, breathing exercises can help improve lung function.

Correct Answer: A

Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.

Correct Answer: B

Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation. Rationale: 1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings. 2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support. 3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication. 4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress. Summary of other choices: A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively. C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears. D: Incorrect. While the response did minimize the patient

Correct Answer: D

Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.

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 because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background. Explanation for why other choices are incorrect: A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective. B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions. D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.

Correct Answer: B

Rationale: The correct answer is B because stopping insulin when blood sugar is normal can lead to hyperglycemia. A: Monitoring blood sugar is essential for diabetes management. C: Eating balanced diet and exercising help control blood sugar levels. D: Avoiding sugary foods is important to manage blood sugar.