Nokea
A nurse is assessing a patient's breath sounds and notes that the patient has a wheeze. This is most likely indicative of:
- A. Pneumonia.
- B. Asthma.
- C. Pulmonary embolism.
- D. Pleural effusion.
Correct Answer: B
Rationale: The correct answer is B: Asthma. Wheezing is a high-pitched whistling sound heard during expiration caused by narrowed airways in conditions like asthma. Pneumonia (A) typically presents with crackles, not wheezes. Pulmonary embolism (C) may cause sudden chest pain and shortness of breath but not wheezing. Pleural effusion (D) results in decreased breath sounds, not wheezes.
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Which organ is responsible for the extensive metabolism of acetaminophen?
- A. Liver
- B. Kidneys
- C. Lungs
- D. Pancreas
Correct Answer: A
Rationale: The correct answer is A: Liver. The liver is responsible for the extensive metabolism of acetaminophen through various pathways, including glucuronidation, sulfation, and oxidation. It converts acetaminophen into less toxic metabolites for elimination. The kidneys (B) primarily filter blood and regulate fluid balance; the lungs (C) are involved in gas exchange; and the pancreas (D) produces digestive enzymes and insulin, not involved in acetaminophen metabolism. Therefore, the liver is the correct choice for this question.
A nurse is caring for a patient with chronic heart failure. Which of the following interventions is the priority?
- A. Administering diuretics as prescribed.
- B. Encouraging the patient to rest.
- C. Monitoring vital signs and fluid status.
- D. Teaching the patient about dietary changes.
Correct Answer: C
Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.
What is the most common complication associated with cancer patients taking opioids?
- A. Tolerance
- B. Sedation
- C. Addiction
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Sedation. Cancer patients taking opioids commonly experience sedation due to the central nervous system depressant effects of opioids. Opioids can cause drowsiness, fatigue, and decreased alertness. Tolerance (A) is a possible issue but is not the most common complication. Addiction (C) is less common in cancer patients due to the nature of their pain management. Constipation (D) is a common side effect of opioids but is not the most common complication in cancer patients. Sedation is the most prevalent issue affecting the quality of life and daily functioning of cancer patients on opioids.
What is the most important intervention for a client with acute pancreatitis?
- A. Administer pain relief
- B. Administer fluids
- C. Administer IV fluids
- D. Administer nitroglycerin
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.
A nursing diagnosis made by a critical thinker using a dynamic nursing process would identify the actual problem and would also:
- A. continue to reassess.
- B. predict potential problems.
- C. check the appropriateness of goals.
- D. modify the diagnosis if necessary.
Correct Answer: B
Rationale: The correct answer is B because critical thinking involves anticipating potential issues to provide proactive care. By predicting potential problems, nurses can prevent complications and tailor interventions accordingly. This step is essential in the nursing process to ensure comprehensive and effective care. Continuing to reassess (A) is important but not the primary focus of a nursing diagnosis. Checking the appropriateness of goals (C) is crucial but comes after identifying the problem and predicting potential issues. Modifying the diagnosis if necessary (D) is a part of critical thinking but not the immediate next step after identifying the actual problem.