A nurse is assisting with the care of a client in an outpatient provider's office.
The nurse should identify that the client is at risk of developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.
Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.
The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.
Correct Answer is D
Explanation
The correct answer is choiced. "Soiled dressings should be placed in a biohazard trash receptacle.".
Choice A rationale:
For a client who has Clostridium difficile, hand hygiene should be performed with soap and water, not an alcohol-based rub, as alcohol does not effectively kill C. difficile spores.
Choice B rationale:
Droplet precautions typically require wearing a mask, not necessarily a gown and gloves. Gown and gloves are more commonly associated with contact precautions.
Choice C rationale:
Following a blood spill, a bleach solution with a ratio of 1 to 10 is recommended, not 1 to 20. This higher concentration ensures effective disinfection.
Choice D rationale:
Placing soiled dressings in a biohazard trash receptacle is correct. This prevents the spread of infection and ensures proper disposal of contaminated materials.
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