Nokea
What is the most appropriate intervention for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological assessment
Correct Answer: A
Rationale: Administering oxygen is the most appropriate intervention for a patient with confusion post-surgery because it helps alleviate confusion caused by potential hypoxia. In a post-surgical setting, confusion can be a sign of decreased oxygen levels in the blood due to various reasons such as respiratory depression, decreased lung function, or other complications. Administering oxygen can quickly address hypoxia, improving oxygenation to the brain and reducing confusion. Repositioning the patient, administering IV fluids, or performing a neurological assessment are not the primary interventions for confusion related to hypoxia post-surgery.
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A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Preoccupation with somatic disturbances
- D. Poor problem-solving ability
Correct Answer: B
Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?
- A. Oxygen saturation of 92%
- B. Use of pursed-lip breathing
- C. Increased anterior-posterior chest diameter
- D. Productive cough with green sputum
Correct Answer: D
Rationale: The correct answer is D. A productive cough with green sputum can indicate a bacterial infection, which is a concern for clients with COPD. Reporting this finding to the provider is important for further evaluation and management. Choices A, B, and C are not as concerning in the context of COPD management. An oxygen saturation of 92% is within an acceptable range for COPD patients, pursed-lip breathing is a helpful technique for managing breathing difficulties in COPD, and an increased anterior-posterior chest diameter is a common finding in clients with COPD due to chronic air trapping.
A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?
- A. Use a cuff that is too loose for the arm.
- B. Place the cuff over clothing.
- C. Sit quietly for 5 minutes before measuring your blood pressure.
- D. Use the same arm for each reading.
Correct Answer: C
Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.
A healthcare professional is reviewing the laboratory results of a client who is receiving chemotherapy. Which of the following findings should the healthcare professional report immediately?
- A. White blood cell count of 4,500/mm³
- B. Hemoglobin level of 8 g/dL
- C. Platelet count of 90,000/mm³
- D. Serum potassium level of 3.5 mEq/L
Correct Answer: C
Rationale: A platelet count of 90,000/mm³ indicates thrombocytopenia, which increases the risk of bleeding and requires immediate intervention. Thrombocytopenia can lead to serious bleeding complications, so it is crucial to address this finding promptly. A low white blood cell count (choice A) may indicate neutropenia but is not as immediately life-threatening as severe thrombocytopenia. A hemoglobin level of 8 g/dL (choice B) would require intervention but is not as urgent as addressing a critically low platelet count. A serum potassium level of 3.5 mEq/L (choice D) is on the lower side of normal but does not pose an immediate risk to the client's safety compared to severe thrombocytopenia.
A nurse is reviewing the medication record of a client with chronic kidney disease. Which of the following medications should the nurse question?
- A. Calcium carbonate
- B. Furosemide
- C. Epoetin alfa
- D. Spironolactone
Correct Answer: D
Rationale: The correct answer is D, Spironolactone. Spironolactone is a potassium-sparing diuretic, which may lead to hyperkalemia in clients with chronic kidney disease. Therefore, its use should be questioned in this population. Choice A, Calcium carbonate, is commonly used to manage phosphate levels in chronic kidney disease. Choice B, Furosemide, is a loop diuretic that helps with fluid retention but should be used with caution in kidney disease. Choice C, Epoetin alfa, is a medication used to stimulate red blood cell production in clients with chronic kidney disease and anemia.