The patient has experienced a myocardial infarction, resulting in damage to the left ventricle. Which of the following does the nurse know the patient may experience as a possible complication?
a. Jugular neck vein distension
b. Pulmonary congestion
c. Peripheral edema
d. Liver enlargement
B
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A Jugular neck vein distension is characteristic of right-sided heart failure.
B Pulmonary congestion may be experienced in left-sided heart failure.
C Peripheral edema is characteristic of right-sided heart failure.
D Hepatomegaly (liver enlargement) is characteristic of right-sided heart failure.
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A community health nurse is engaged in collaboration. Which of the following distinguishes collaboration from other types of interactions?
A) Focusing on shared goals and mutual participation B) Including the client as a member of the team each time C) Lengthening the time needed to meet goals D) Including flexible boundaries and responsibilities
A nurse is working in a women's hospital where she is caring for a new mother who is experiencing postpartum urinary retention. Bethanechol (Urecholine) has been ordered. The nurse will observe for which of the following?
A) Bradycardia B) Hypertension C) Hypotension D) Decreased salivation
The nurse is caring for an 88-year-old patient who was admitted to the long-term care facility after a recent conviction of driving while intoxicated. On reviewing the laboratory work and ob-serving a folic acid level of 2 ng/ml, the nurse
a. increases the patient's caloric intake. b. performs a dietary assessment on the pa-tient. c. provides the patient with sodium-rich foods. d. immediately notifies the patient's physi-cian.
When performing a venipuncture for a specimen, the nurse should
a. select an arm in which an IV is infusing b. apply the tourniquet 3 to 4 inches above the elbow c. not palpate a distal pulse following applica-tion of the tourniquet d. select a vein that is not dilated