Extract:

Question 1 of 5

Crackles heard on lung auscultation indicate which of the following?

Correct Answer: D

Rationale: Crackles indicate fluid in the alveoli, often due to pulmonary edema in heart failure or post-MI, reflecting left ventricular dysfunction.

Question 2 of 5

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

A. Monitor daily weights and urine output. B. Permit unrestricted visitation by family and friends. C. Provide client education on medications and diet. D. Reduce pain and myocardial oxygen demand.

Correct Answer: D

Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.

Question 3 of 5

A client tells the nurse his vision is blurred and hazy throughout the entire day. The nurse should recommend that the client do which of the following?

A. Purchase a pair of magnifying glasses. B. Wear glasses with tinted lenses. C. Schedule an appointment with an optician. D. Schedule an appointment with an ophthalmologist.

Correct Answer: D

Rationale: An ophthalmologist is a physician who specializes in the treatment of disorders of the eye, and the nurse should advise the client to see a physician. An optician makes glasses, and it is not known at this point what the best treatment for the client is. Magnifying glasses or tinted lenses do not correct hazy or blurred vision.

Question 4 of 5

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:

A. Encourage the client to increase fl uid intake. B. Withhold the next dose of antihypertensive medication. C. Restrict the client’s sodium intake. D. Encourage the client to eat at least half of a banana per day

Correct Answer: A

Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

Question 5 of 5

Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?

A. Avoid showering for 48 hours after surgery. B. Return to work within 1 week. C. Leave dressings in place until you see the surgeon at the postoperative visit. D. Use acetaminophen (Tylenol) to control any fever.

Correct Answer: B

Rationale: Returning to work within 1 week (
B) is reasonable for laparoscopic cholecystectomy, depending on recovery. Showering is typically allowed after 24-48 hours (A is incorrect). Dressings can often be removed sooner (
C), and acetaminophen is for pain, not fever control (
D).