Question

A client with a history of heart failure presents with progressive shortness of breath over the last several days. Upon assessment, the nurse notes jugular venous distention, crackles in the lung bases auscultated bilaterally, and a bounding pulse. Which of the following interventions would be the nurse's priority?

Answer 1

Correct Answers:

Administration of IV diuretics

Rationale :

💉Heart failure leads to fluid overload, which causes symptoms such as jugular venous distention, crackles, and a bounding pulse due to increased preload and pulmonary congestion.

👉IV diuretics, such as furosemide, are the priority intervention as they rapidly reduce intravascular volume, relieve pulmonary symptoms, and decrease cardiac workload.

💊Prompt administration can prevent further complications like acute pulmonary edema or respiratory failure.

📈Administering IV fluids or laying the client supine would worsen the situation by increasing venous return and further overloading the heart.

📌core message

The priority treatment for heart failure with fluid overload is IV diuretics to reduce volume and relieve symptoms.

Answer 2

Correct Answers:

Obtain a 12-lead ECG.

Rationale :

📈Hyperkalemia can cause life-threatening cardiac arrhythmias, especially when potassium levels exceed 6.5 mEq/L.

💁‍♂️A 12-lead ECG is essential to detect early cardiac conduction abnormalities such as peaked T waves, widened QRS, or heart block.

⚠️This diagnostic step is urgent to guide the immediate management and prevent cardiac arrest.

📊Monitoring serum sodium or advising on salt substitutes is not a priority when cardiac function is threatened.

📌core message

In severe hyperkalemia, obtain an ECG first to assess for cardiac instability.

Answer 3

Correct Answers:

Prepare the client to go back to the operating room
Notify the surgeon

Rationale :

🦵Symptoms like numbness, no pedal pulse, and no motor function suggest compartment syndrome, a surgical emergency.

🚑Prompt intervention is needed to prevent irreversible ischemia or amputation of the affected limb.

📞The nurse must immediately notify the surgeon and prepare for a possible fasciotomy.

🚫Elevation or ice can worsen ischemia by reducing blood flow to tissues, and amputation is not an initial action.

📌core message

Compartment syndrome requires urgent surgical evaluation and notification of the surgeon.

Answer 4

Correct Answers:

300

Rationale :

🕒The time from 0330 to 0600 is 2.5 hours.

💧At 120 mL/hr, total fluid infused = 120 × 2.5 = 300 mL.

🧾Accurate documentation of IV fluid intake ensures proper monitoring of fluid status and therapy effectiveness.

📋This is especially important in clients at risk for fluid overload or deficit.

📌core message

Multiply infusion rate by elapsed time to track IV fluid intake.

Answer 5

Correct Answers:

Flattened T wave

Rationale :

📉Hypokalemia alters the myocardial cell’s repolarization phase, leading to flattened or inverted T waves.

🧠Prolonged vomiting causes potassium depletion, commonly seen in clinical practice.

📋An ECG is a crucial tool to detect electrolyte-induced cardiac changes early.

🚨If untreated, this may lead to dangerous arrhythmias or cardiac arrest.

📌core message

Flattened T waves are a key sign of hypokalemia on ECG.

Answer 6

Correct Answers:

Jugular vein distention
Crackles
Dyspnea

Rationale :

💁‍♂️Jugular vein distension, crackles, and dyspnea are hallmark signs of fluid volume excess.

📈These signs indicate fluid accumulation in the vascular and pulmonary systems, often due to overload or heart failure.

🚰Careful monitoring is essential to prevent complications like pulmonary edema.

📛Flat neck veins and hypotension are associated with volume deficit, not overload.

📌core message

Signs of hypervolemia include JVD, crackles, and dyspnea.

Answer 7

Correct Answers

Blank 1 Correct Option: self neglect
Blank 2 Correct Option: antibiotic therapy

Rationale :

🧠The client’s disorientation, fever, and incontinence point to possible infection with cognitive decline, signaling self-neglect as the initial concern.

💉Prompt antibiotic therapy is then necessary to manage the underlying UTI or sepsis.

🏠Addressing self-neglect helps identify factors like poor hygiene, cognitive issues, or social isolation.

📊Addressing psychosocial and physical priorities in order ensures safe and effective care planning.

📌core message

Address self-neglect first, then initiate infection treatment.

Answer 8

Correct Answers:

Fluid and electrolyte imbalance

Rationale :

💩Severe diarrhea causes massive fluid and electrolyte loss, risking hypovolemia and electrolyte imbalance.

⚠️This imbalance can lead to cardiac dysrhythmias, hypotension, and organ dysfunction.

💊While pain and nutrition are important, preventing life-threatening fluid loss takes priority.

🧪Early correction with IV fluids and monitoring helps prevent complications.

📌core message

In Crohn’s flare with diarrhea, fluid and electrolyte imbalance is the top priority.

Answer 9

Correct Answers:

Increase fluid intake to at least 3 L/day to dilute the urine.

Rationale :

🚽Increasing hydration promotes urinary flushing, reducing bacterial colonization and preventing recurrent infections.

👩🏻‍🤝‍🧑🏿Clients with chronic pyelonephritis benefit from adequate urine flow to prevent stagnation and stone formation.

📉Fluid restriction or delayed voiding increases the risk of infection or kidney damage.

🧂Sodium restriction is less relevant unless client has coexisting renal or cardiac issues.

📌core message

Increased fluid intake is essential to flush bacteria and prevent pyelonephritis.

Answer 10

Correct Answers:

Hypertonic saline may be administered to shift fluid out of brain tissue.

Rationale :

🧠Hypertonic saline (e.g., 3% NaCl) is used in cerebral edema to draw water out of brain cells and reduce intracranial pressure.

🧪This osmotic effect helps prevent brain herniation and neurological damage.

🚫It is contraindicated in hypernatremia, not cerebral edema.

📋Hypertonic fluids must be administered carefully, usually in ICU settings with close monitoring.

📌core message

Hypertonic saline shifts fluid out of brain cells to reduce cerebral edema.

2 :
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

5 :
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

6 :
A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

7 :
A nurse is caring for a client in the emergency department (ED)

Correct Answers

8 :
The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

9 :
The nurse is providing education to a patient with chronic pyelonephritis about health promotion activities. Which of the following actions should the nurse include in the teaching?

10 :
Which of the following statements regarding hypertonic (3%) sodium chloride is correct?

2 : A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

4 : A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

5 : A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

6 : A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

7 : A nurse is caring for a client in the emergency department (ED)

Correct Answers

8 : The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

9 : The nurse is providing education to a patient with chronic pyelonephritis about health promotion activities. Which of the following actions should the nurse include in the teaching?

10 : Which of the following statements regarding hypertonic (3%) sodium chloride is correct?

2 :
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

5 :
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

6 :
A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

7 :
A nurse is caring for a client in the emergency department (ED)

8 :
The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

9 :
The nurse is providing education to a patient with chronic pyelonephritis about health promotion activities. Which of the following actions should the nurse include in the teaching?

10 :
Which of the following statements regarding hypertonic (3%) sodium chloride is correct?