The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client?

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Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions

Question 1 of 5

The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client?

Correct Answer: C

Rationale: Monitoring serum electrolyte levels would be the most appropriate action for a client admitted with a cardiac dysrhythmia. Electrolyte imbalances, particularly potassium and magnesium, can lead to cardiac dysrhythmias. Therefore, it is crucial to monitor and maintain proper electrolyte levels to prevent or manage dysrhythmias. Restricting fluids, encouraging bedrest, or instructing in a low-fat diet are not the priority actions for managing a cardiac dysrhythmia.

Question 2 of 5

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?

Correct Answer: B

Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.

Question 3 of 5

During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke?

Correct Answer: A

Rationale: Jerking movements in the face, arms, or legs can be a sign of seizures, which can occur as a result of a stroke in infants. This question is important to assess whether the infant may have experienced any seizure activity, which could indicate a potential stroke. It helps the nurse gather more information to understand the infant's symptoms and assess the possibility of a stroke event.

Question 4 of 5

An older patient is experiencing constipation. What should the nurse teach this patient to help with this health problem? Select all that apply.

Correct Answer: A

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

Question 5 of 5

A patient has difficulty getting to the bathroom in time to prevent urine leaks once the need to void occurs. What should the nurse teach this patient?

Correct Answer: B

Rationale: Establishing a voiding schedule that includes emptying the bladder at least every 2 hours can help prevent urine leaks in this patient. By regularly emptying the bladder, the patient can reduce the likelihood of urgency and leakage episodes. This strategy helps in managing the symptoms of urge incontinence or overactive bladder, which seem to be the underlying issues for the patient described in the scenario. The other options may also be helpful in managing urinary incontinence but creating a voiding schedule is the most direct and effective approach for the patient's specific concern.

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