The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping eﬀectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

Myocardial Infarction.

Atelectasis.

Fluid volume deficit.

Fluid volume excess.

Answer and Explanation

The Correct Answer is D

Heart failure is a condition in which the heart is unable to pump blood eﬀectively, leading to a buildup of ﬂuid in the body. This can result in edema (swelling) and ﬂuid accumulation in the lungs, causing coarse crackles when breathing. The term for this condition is ﬂuid volume excess, which refers to an excessive amount of ﬂuid in the body.

Myocardial infarction is a heart attack, atelectasis is a collapse of lung tissue, and ﬂuid volume deficit refers to a lack of ﬂuid in the body.

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Correct Answer is B

Explanation

The nurse would question the discharge of a client to be cared for by the family if the client and family lack knowledge of the treatment regimen. It is important for the client and family to have a good understanding of the treatment regimen in order to provide safe and eﬀective care at home. The other options (The client will need sterile dressing changes, The client will be discharged with a feeding tube, and The client will be receiving IV medications by home health nurses) are not situations that would necessarily prevent discharge to be cared for by the family.

A. This was an older client. B. The unit has a new wheelchair. C. The UAP had just returned from an extended leave of absence. D. It was the client's first time out of bed after surgery.

Correct Answer is D

Explanation

It would be inappropriate to delegate the unsupervised task of transferring a client from bed to chair to an unlicensed assistant (UAP) if it was the client's first time out of bed after surgery. In this situation, the client may have specific needs or limitations that require the expertise and assessment of a licensed healthcare provider. The nurse should supervise the transfer to ensure that it is performed safely and appropriately for the client's condition.

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The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping eﬀectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?

Correct Answer is B

Explanation

An unlicensed assistant (UAP) has previously performed client transfers safely (bed to chair) on many occasions. It would be inappropriate to delegate this unsupervised task to the UAP under which condition?

Correct Answer is D

Explanation

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time?

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me an antibiotic." What would be the most appropriate response by the nurse?

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?