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1. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
- A. Serum albumin level of 3 g/dL
- B. HDL level of 90 mg/dL
- C. Norton scale score of 18
- D. Braden scale score of 20
Correct answer: A
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.
2. What are the primary differences between left-sided and right-sided heart failure?
- A. Left-sided: Pulmonary congestion; Right-sided: Systemic edema
- B. Right-sided: Pulmonary congestion; Left-sided: Systemic edema
- C. Left-sided: Systemic edema; Right-sided: Pulmonary congestion
- D. Right-sided: Pulmonary congestion; Left-sided: Heart failure
Correct answer: A
Rationale: The correct answer is A: "Left-sided: Pulmonary congestion; Right-sided: Systemic edema." Left-sided heart failure primarily affects the lungs, leading to pulmonary congestion, which manifests as symptoms like shortness of breath and cough. On the other hand, right-sided heart failure causes systemic congestion and edema, often presenting as swelling in the legs and abdomen due to fluid retention. Choice B is incorrect because it swaps the features of left-sided and right-sided heart failure. Choice C is incorrect as it also incorrectly switches the characteristics of the two types of heart failure. Choice D is incorrect because it inaccurately associates left-sided heart failure with pulmonary congestion and right-sided heart failure with heart failure itself, which is not a distinguishing feature.
3. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?
- A. Move both crutches up first
- B. Step up with the unaffected leg first
- C. Lean forward on the crutches before stepping up
- D. Hold onto the handrail for support
Correct answer: B
Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.
4. A client is being taught about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication on an empty stomach.
- B. If I forget to take a dose, I can take it later on the same day.
- C. I will skip my dose if I forget to take it.
- D. I can take an additional dose if I miss one.
Correct answer: B
Rationale: The correct answer is B because taking warfarin later on the same day if a dose is missed helps maintain therapeutic levels. Choice A is incorrect because warfarin should be taken with food to enhance absorption. Choice C is incorrect as skipping a dose can lead to fluctuations in warfarin levels. Choice D is incorrect as taking an additional dose can increase the risk of bleeding.
5. A client receiving chemotherapy is experiencing fatigue. Which intervention should the nurse implement to manage the client's fatigue?
- A. Encourage the client to take short naps during the day
- B. Instruct the client to remain on bedrest
- C. Provide the client with a high-calorie diet
- D. Encourage the client to increase activity levels
Correct answer: A
Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (Choice B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (Choice C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (Choice D) may exacerbate fatigue instead of alleviating it.
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