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1. What are the complications of untreated fluid overload?
- A. Pulmonary edema and congestive heart failure
- B. Hypertension and electrolyte imbalance
- C. Liver failure and electrolyte imbalance
- D. Pulmonary embolism and dehydration
Correct answer: A
Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.
2. What is the correct way to assess for pitting edema?
- A. Press over the bony area for 5 seconds and release
- B. Press over the skin for 10 seconds and check for discoloration
- C. Press the area and check for the presence of rash
- D. Press the skin and assess for rebound tenderness
Correct answer: A
Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.
3. A nurse is teaching a client who has multiple sclerosis (MS) about strategies to reduce fatigue. Which of the following instructions should the nurse include?
- A. Exercise to the point of exhaustion
- B. Rest as needed throughout the day
- C. Avoid physical activity
- D. Exercise only once per week
Correct answer: B
Rationale: The correct instruction the nurse should include is to 'Rest as needed throughout the day.' Fatigue is a common symptom of multiple sclerosis (MS), and adequate rest is essential to manage it effectively. Resting as needed helps conserve energy and prevent fatigue from worsening. Choices A, C, and D are incorrect. 'Exercise to the point of exhaustion' is not recommended as it can lead to increased fatigue. 'Avoiding physical activity' entirely is not advisable as appropriate exercise can help maintain strength and energy levels. 'Exercising only once per week' may not be sufficient to combat fatigue and maintain overall well-being in clients with MS.
4. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?
- A. Heart rate 56/min.
- B. Oxygen saturation 93%.
- C. Respiratory rate 18/min.
- D. Blood pressure 118/74 mm Hg.
Correct answer: A
Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.
5. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?
- A. White flour tortillas.
- B. Potato pancakes.
- C. Wheat crackers.
- D. Canned barley soup.
Correct answer: B
Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.
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