Nokea
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following to prevent complications?
- A. Administering pain medication regularly.
- B. Encouraging deep breathing exercises.
- C. Monitoring for signs of infection.
- D. Encouraging early ambulation.
Correct Answer: D
Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.
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What is the nurse's priority when caring for a client with respiratory distress?
- A. Administer oxygen
- B. Administer albuterol
- C. Place the client on their back
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.
A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?
- A. Ask the patient to explain what they are feeling and what might have caused the behavior.
- B. Remain silent and allow the patient to continue at their own pace.
- C. Ask the patient if they feel nervous or worried about the pregnancy.
- D. Focus on making the patient feel heard and understood.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported.
Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
- A. I know that my name is John. I couldn't tell you where I am. I think this year is 2009, though.
- B. I know that my name is John, but to tell you the truth, I get kind of confused about the date.
- C. I know that my name is John; I guess I'm at the hospital in Victoria. No, I don't know the date.
- D. I know that my name is John. I am at the hospital in Victoria. I couldn't tell you what date it is, but I know that it is February of a new year"”2009.
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains.
Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.
A nurse is caring for a patient with diabetes who is newly diagnosed with diabetic nephropathy. The nurse should prioritize which of the following assessments?
- A. Kidney function tests.
- B. Blood pressure measurement.
- C. Blood glucose levels.
- D. Urine output monitoring.
Correct Answer: A
Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.