An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

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Question 1 of 5

An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

Correct Answer: A

Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.

Question 2 of 5

A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

Correct Answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

Question 3 of 5

Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?

Correct Answer: A

Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.

Question 4 of 5

At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?

Correct Answer: A

Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.

Question 5 of 5

A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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