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A nurse in a provider's clinic is caring for a client who has heart failure. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I drink at least 3 liters of water every day to stay hydrated."
B. "I am limiting my sodium intake to 2 grams daily."
C. "I skip meals when I feel full."
D. "I ignore small weight changes, as they are normal."
Correct answer: B. "I am limiting my sodium intake to 2 grams daily."
Rationale: Limiting sodium intake helps control fluid retention, which is critical for
managing heart failure.
Which of the following additional statements also demonstrate understanding of
heart failure management teaching?
A. "I am eating fewer potato chips and more fruit for snacks."
B. "I have been eating more processed foods to gain energy."
C. "I avoid weighing myself to reduce anxiety."
D. "I don't need to track my daily weight."
Correct answer: A. "I am eating fewer potato chips and more fruit for snacks."
Rationale: Reducing high-sodium snacks like chips and increasing fruit intake
supports heart health.
,Which statement by the client indicates appropriate monitoring for worsening
heart failure?
A. "I only call my doctor if I gain 10 pounds in a week."
B. "I weigh myself monthly."
C. "I know to call my doctor if I gain 3 pounds or more in 2 days."
D. "I weigh myself at night."
Correct answer: C. "I know to call my doctor if I gain 3 pounds or more in 2
days."
Rationale: Sudden weight gain can indicate fluid retention and worsening heart
failure.
A nurse in an emergency department is caring for a confused client. What should
the nurse do first?
A. Administer sedative medication.
B. Review medications that might cause confusion.
C. Encourage the client to walk independently.
D. Leave the client alone to rest.
Correct answer: B. Review medications that might cause confusion.
Rationale: Identifying medication-related causes of confusion is a priority to
ensure patient safety and direct further care.
A nurse is caring for a client with a pressure injury. Which finding should the nurse
report to the provider?
A. Skin blanching around the wound
B. Elevated temperature and white blood cell count
C. Intact peri-wound skin
D. Serous drainage only
, Correct answer: B. Elevated temperature and white blood cell count
Rationale: These are signs of possible infection, requiring provider notification
and possible intervention.
A nurse is caring for a client newly diagnosed with a seizure disorder. What is the
nurse’s priority action?
A. Notify the pharmacy.
B. Reposition the client to a comfortable chair.
C. Check for environmental safety and then reposition the client.
D. Call the family immediately.
Correct answer: C. Check for environmental safety and then reposition the
client.
Rationale: Ensuring safety is the priority to prevent injury during a seizure.
A nurse is admitting a client and reviewing the medical record. Which of the
following actions should the nurse take?
A. Place the client in airborne isolation.
B. Apply oxygen at 6 LPM via mask.
C. Remain 1 meter (3 feet) from the client.
D. Encourage the client to walk around.
Correct answer: C. Remain 1 meter (3 feet) from the client.
Rationale: This is an appropriate droplet precaution measure to prevent
transmission of infectious agents.
Which of the following findings indicate the client in the emergency department is
malnourished?
A. Flaccid muscle tone, dry scaly skin with bruises, BMI 17
B. Firm muscle tone, clear skin, BMI 23