Nokea
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions to prevent complications?
- A. Administering pain medication as needed.
- B. Encouraging early ambulation and use of compression stockings.
- C. Providing nutritional support and supplements.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.
You may also like to solve these questions
A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administering pain medication.
- B. Monitoring vital signs and oxygen saturation.
- C. Encouraging deep breathing exercises.
- D. Providing nutritional education.
Correct Answer: B
Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.
A nurse is teaching a patient with a new diagnosis of diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I should follow a healthy diet to manage my condition.
- C. I can stop taking my insulin when my blood sugar is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale:
1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications.
2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective.
3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers.
4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.
Which of the following statements best describes the Montreal Cognitive Assessment (MoCA) examination?
- A. Scores below 30 indicate cognitive impairment.
- B. It is a good tool to evaluate mood and thought processes.
- C. It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
- D. It is useful for an initial evaluation of mental health. Additional tools are needed to evaluate changes in cognition over time.
Correct Answer: C
Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia.
Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level.
Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes.
Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.
A nurse is assessing a patient who is experiencing shortness of breath and a cough that produces thick, green sputum. Which of the following conditions should the nurse be most concerned about?
- A. Asthma.
- B. Bronchitis.
- C. Pneumonia.
- D. Pulmonary embolism.
Correct Answer: C
Rationale: The correct answer is C: Pneumonia. The patient's symptoms of shortness of breath and cough with thick, green sputum suggest an acute infection in the lungs. Pneumonia is characterized by inflammation and infection of the lung tissue, leading to symptoms such as productive cough, shortness of breath, and sputum production. It is a serious condition that requires prompt treatment with antibiotics.
A: Asthma typically presents with wheezing, chest tightness, and shortness of breath triggered by certain stimuli, but not usually with thick, green sputum.
B: Bronchitis is inflammation of the bronchial tubes, characterized by cough with clear or slightly discolored sputum, not typically thick and green.
D: Pulmonary embolism is a blockage in the arteries of the lungs, causing sudden shortness of breath and chest pain, but not usually associated with green sputum production.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?' The nurse tells her:
- A. They are signs of decreased hematocrit related to anemia.
- B. They are due to destruction of melanin in your skin due to exposure to the sun.
- C. They are clusters of melanocytes that appear after prolonged sun exposure.
- D. They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction.
Correct Answer: C
Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation.
Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.