Question

Which assessment finding should the nurse expect in a client with fluid volume excess?

Answer 1

Correct Answers:

Elevated blood pressure.

Rationale :

💧In fluid volume excess, there is increased circulatory volume, which leads to elevated blood pressure due to higher preload and systemic vascular resistance.

💧Other expected signs include bounding pulses, edema, jugular vein distention, and crackles on lung auscultation.

💧The cardiovascular system reflects this overload as the body struggles to maintain perfusion.

💧Hypertension in this case is a direct clinical indicator of excess volume.

💧Continuous monitoring of blood pressure, weight, and intake/output is essential for safe management.

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Answer 2

Correct Answers:

Decreases inflammation and pain

Rationale :

🌿The combination otic solution contains hydrocortisone (anti-inflammatory), neomycin, and polymyxin B (antibiotics).

🌿Hydrocortisone specifically reduces inflammation, which helps relieve pain, itching, and swelling.

🌿This action enhances comfort while antibiotics control infection.

🌿Effective management of inflammation also improves the patient’s ability to tolerate therapy.

🌿Educating the patient about expected symptom relief prevents anxiety about ongoing discomfort.

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Answer 3

Correct Answers:

Use contraception during intercourse

Rationale :

⚠️Misoprostol (Cytotec) is a prostaglandin analog used to prevent NSAID-induced gastric ulcers but is teratogenic.

⚠️It can cause uterine contractions, miscarriage, and congenital malformations if taken during pregnancy.

⚠️Therefore, women of childbearing age must use effective contraception while on misoprostol.

⚠️This teaching is the most critical safety point to prevent severe adverse outcomes.

⚠️The nurse’s role includes emphasizing reproductive precautions when prescribing this drug.

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Answer 4

Correct Answers:

Gram-negative organisms are more resistant to antibiotic therapy

Rationale :

🦠Gram-negative pneumonias are associated with higher mortality because the organisms have complex cell walls and resistance mechanisms.

🦠They produce endotoxins, making them harder to treat with standard antibiotics.

🦠Patients often require broad-spectrum or multiple antibiotic regimens for effective management.

🦠This resistance leads to prolonged illness and increased risk of sepsis and respiratory failure.

🦠Hence, prognosis is poorer compared to pneumococcal pneumonia.

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Answer 5

Correct Answers:

Every 12 hours.

Rationale :

💊Controlled-release oxycodone is formulated to release medication slowly over 12 hours.

💊Teaching patients to take it twice daily at consistent times ensures stable analgesia.

💊This reduces breakthrough pain and maintains steady plasma drug levels.

💊Taking it more frequently increases risk of toxicity and respiratory depression.

💊Patient education should include avoiding crushing or chewing the tablet to prevent dose dumping.

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Answer 6

Correct Answers:

Amount of retinal vessel damage that has occurred.

Rationale :

👁Hypertension causes retinopathy, which can be observed during an ophthalmoscopic exam.

👁The severity of retinal vessel damage (narrowing, hemorrhages, exudates, papilledema) directly correlates with hypertension severity.

👁Retinal changes are valuable diagnostic markers of long-standing or poorly controlled hypertension.

👁Early detection can prevent progression to vision loss and further organ damage.

👁This makes retinal examination a crucial part of hypertension assessment.

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Answer 7

Correct Answers:

Administer the dose with a snack.

Rationale :

🥗Albuterol tablets may cause gastrointestinal irritation, leading to nausea.

🥗Giving the medication with food or a snack helps buffer the stomach lining, reducing side effects.

🥗This intervention does not interfere with drug absorption.

🥗It is a safe and simple strategy to improve treatment adherence.

🥗Nurses should encourage patients to take it with a light snack, not an empty stomach.

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Answer 8

Correct Answers:

Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

Rationale :

🍃Diverticulosis occurs when increased intraluminal pressure (often due to chronic constipation) causes weak spots in the colon wall to bulge outward.

🍃These out-pouchings (diverticula) are most common in the sigmoid colon.

🍃Risk factors include low-fiber diets, aging, and sedentary lifestyle.

🍃While diverticulosis itself is asymptomatic, it can progress to diverticulitis if inflamed.

🍃Education should focus on fiber-rich diets and hydration to prevent complications.

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Answer 9

Correct Answers:

Genetic counseling should be obtained prior to undertaking any genetic testing procedure.

Rationale :

🧬Huntington’s disease is an autosomal dominant disorder with a 50% inheritance risk.

🧬Testing adolescents raises ethical and psychological issues since the disease is progressive, incurable, and adult-onset.

🧬Genetic counseling provides families with informed guidance on risks, implications, and alternatives.

🧬It also addresses potential emotional, social, and insurance concerns before testing.

🧬Nurses should advocate for counseling as the first step in decision-making.

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Answer 10

Correct Answers:

Rash.

Rationale :

🌸A rash while on ampicillin may indicate a serious allergic reaction (hypersensitivity).

🌸Ampicillin belongs to the penicillin family, which carries a risk of anaphylaxis.

🌸Early recognition of rash can prevent progression to life-threatening reactions.

🌸Patients should be instructed to notify their provider immediately if rash develops.

🌸Nurses must monitor for other signs of allergy, including itching, swelling, and respiratory distress.

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QLexNursing

1 :
Which assessment finding should the nurse expect in a client with fluid volume excess?

2 :
A client is using an otic solution, hydrocortisone, neomycin, and polymyxin B for external otitis media. Which therapeutic response should the nurse tell the client to expect?

3 :
A female client with rheumatoid arthritis takes ibuprofen 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching?

5 :
A client is prescribed controlled-release oxycodone. Which dosing schedule is best for the nurse to teach the client?

6 :
The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?

7 :
A client prescribed albuterol tablets reports nausea every evening with the 9:00 p.m. dose. Which action should the nurse perform to alleviate this side effect?

8 :
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula?

9 :
A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. Whish response is best for the nurse to provide?

10 :
A client is prescribed ampicillin sodium for a sinus infection. The nurse should instruct the client to notify the healthcare provider immediately if which symptom occurs?

QLexNursing

1 : Which assessment finding should the nurse expect in a client with fluid volume excess?

2 : A client is using an otic solution, hydrocortisone, neomycin, and polymyxin B for external otitis media. Which therapeutic response should the nurse tell the client to expect?

3 : A female client with rheumatoid arthritis takes ibuprofen 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching?

5 : A client is prescribed controlled-release oxycodone. Which dosing schedule is best for the nurse to teach the client?

6 : The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?

7 : A client prescribed albuterol tablets reports nausea every evening with the 9:00 p.m. dose. Which action should the nurse perform to alleviate this side effect?

8 : A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula?

9 : A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. Whish response is best for the nurse to provide?

10 : A client is prescribed ampicillin sodium for a sinus infection. The nurse should instruct the client to notify the healthcare provider immediately if which symptom occurs?

1 :
Which assessment finding should the nurse expect in a client with fluid volume excess?

2 :
A client is using an otic solution, hydrocortisone, neomycin, and polymyxin B for external otitis media. Which therapeutic response should the nurse tell the client to expect?

3 :
A female client with rheumatoid arthritis takes ibuprofen 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching?

5 :
A client is prescribed controlled-release oxycodone. Which dosing schedule is best for the nurse to teach the client?

6 :
The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?

7 :
A client prescribed albuterol tablets reports nausea every evening with the 9:00 p.m. dose. Which action should the nurse perform to alleviate this side effect?

8 :
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula?

9 :
A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. Whish response is best for the nurse to provide?

10 :
A client is prescribed ampicillin sodium for a sinus infection. The nurse should instruct the client to notify the healthcare provider immediately if which symptom occurs?