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1. What are the complications of untreated fluid overload?
- A. Pulmonary edema and congestive heart failure
- B. Hypertension and electrolyte imbalance
- C. Liver failure and electrolyte imbalance
- D. Pulmonary embolism and dehydration
Correct answer: A
Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.
2. A nurse is teaching a client who has irritable bowel syndrome (IBS) about dietary modifications. Which of the following instructions should the nurse include?
- A. Increase fiber intake to 35 grams per day
- B. Avoid dairy products
- C. Eat small, frequent meals
- D. Avoid fruits and vegetables
Correct answer: C
Rationale: The correct answer is C: 'Eat small, frequent meals.' Eating small, frequent meals helps manage IBS symptoms by avoiding overloading the digestive system. Choice A is incorrect because increasing fiber intake may worsen symptoms in some individuals with IBS. Choice B is not a blanket recommendation for all IBS patients; some may tolerate dairy products well. Choice D is incorrect as fruits and vegetables are important sources of nutrients and should not be completely avoided unless specific triggers are identified.
3. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?
- A. High workload
- B. Limited knowledge on the subject
- C. Poor lighting
- D. Limited space in the learning area
Correct answer: C
Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.
4. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
5. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?
- A. Apply heat to the affected knee
- B. Avoid placing pillows under the knee
- C. Avoid moving the knee for 2-3 days
- D. Apply ice to the affected knee for 24-48 hours
Correct answer: D
Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.
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