Nokea
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Bowel sounds present in all four quadrants
- B. Temperature of 37.5°C (99.5°F)
- C. Scant urine output
- D. Serosanguineous wound drainage
Correct Answer: D
Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.
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What is the best intervention for a patient experiencing respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Administer IV fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is crucial in ensuring that the patient receives an adequate supply of oxygen to meet the body's demands. Administering bronchodilators (Choice B) may be beneficial in specific respiratory conditions like asthma or COPD but may not be the primary intervention in all cases of respiratory distress. Administering IV fluids (Choice C) may be necessary in cases of dehydration or shock but would not directly address respiratory distress. Providing chest physiotherapy (Choice D) can help mobilize secretions in conditions like cystic fibrosis but is not the first-line intervention for respiratory distress.
What is the most important nursing action for a patient presenting with confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological assessment
Correct Answer: A
Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.
Which medication is used to manage hyperthyroidism?
- A. Levothyroxine
- B. Methimazole
- C. Propylthiouracil
- D. Prednisone
Correct Answer: B
Rationale: Methimazole is the correct answer. It is commonly used to manage hyperthyroidism by inhibiting the production of thyroid hormones. Levothyroxine (Choice A) is actually a medication used to treat hypothyroidism by supplementing thyroid hormones. Propylthiouracil (Choice C) is another anti-thyroid medication used in the management of hyperthyroidism. Prednisone (Choice D) is a corticosteroid and is not typically used in the treatment of hyperthyroidism.
A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?
- A. Carrots
- B. Cottage cheese
- C. Bananas
- D. Broccoli
Correct Answer: D
Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place a sensor on the index finger
Correct Answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.