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The home health nurse is caring for a patient with congestive heart failure (CHF).
Which assessment finding should the nurse report immediately to the physician?
A. Moderate shortness of breath after walking down the hall.
B. A 3 pound weight gain over the course of a week.
C. Heart rate of 104 beats/min after ambulating to the bathroom.
D. Increase urinary output to 50 mL in the last hour. - (answer)Answer:
A. Shortness of breath after walking down the hall.
The nurse is caring for a patient with C. difficile infection. Which action is most
important for the nurse to take?
,A. Only use alcohol-based hand cleanser for hand hygiene.
B. Always wear an impervious mask.
C. Don proper eye protection before providing care.
D. Put the patient on contact plus isolation. - (answer)Answer:
D. Put the patient on contact plus isolation
The nurse is caring for a patient with general sepsis. Which finding should first
alert the nurse to a potential complication that warrants immediate attention?
A. Increased lethargy
B. Sudden coughing
C. Elevated blood pressure
D. Cloudy urine - (answer)Answer:
A. Increased lethargy
,The nurse is teaching a patient about the purpose of his telemetry. Which statement
indicates the nurse's teaching has been successful?
A. "I will need to stay in bed when the monitor is reading my heart waves."
B. "This test will help determine if I have a blockage in my arteries."
C. "If there is a problem with my heart valves, it will show up with telemetry."
D. "The nurses will be able to monitor my heart rate and rhythm." -
(answer)Answer:
D. The nurses will be able to monitor my heart rate and rhythm.
The nurse is working in a trauma unit and is accidentally stuck with an IV needle
following venipuncture of the patient. What is the nurses first action?
A. Immediately begin taking the two- to three-drug regimen.
B. Report the stick to the charge nurse immediately so follow-up can be initiated.
, C. Wash the punctured area with soap and water.
D. Complete an incident report so immediate testing of the patient and nurse can
begin. - (answer)Answer:
C. Wash the punctured area with soap and water.
The nurse is caring for a post-myocardial infarction (MI) patient who has been
started on daily simvastatin (Zocor) and a low-fat diet. Which statement best
indicates the nurse's teaching has been successful?
A. "I will need to have blood work every month while taking Zocor."
B. "I should take Zocor with grapefruit juice to help absorption."
C. " I should call my doctor if I experience unexplained muscle pain."
D. "I should take Zocor an hour before my biggest meal of the day." -
(answer)Answer:
C. "I should call my doctor if I experience unexplained muscle pain."