Nokea
A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for which of the following complications?
- A. Neutropenia.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Chronic pain.
Correct Answer: A
Rationale: The correct answer is A: Neutropenia. During chemotherapy, neutropenia, a decrease in white blood cells, can occur, leading to increased risk of infections. Monitoring for neutropenia is crucial for timely intervention. Hyperkalemia (B) is not commonly associated with chemotherapy. Hypoglycemia (C) is more related to diabetes or insulin therapy. Chronic pain (D) is not a typical complication of chemotherapy. Monitoring for neutropenia allows the nurse to provide appropriate care to prevent infections and ensure the patient's safety.
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A 32-year-old patient shares with the nurse that she has been unwell for 2 weeks. She has had a variety of symptoms and has been treating them with herbs that her mother has provideThe nurse should:
- A. tell the patient that it is the herbs that are making her feel unwell.
- B. ask the patient more about the effects of the herbs.
- C. take a sample of the herbs to send to the laboratory for analysis.
- D. ask the patient's mother to explain the use of the herbs.
Correct Answer: B
Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action.
Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.
What is the most appropriate intervention for a client with suspected peritonitis?
- A. Administer antibiotics
- B. Administer IV fluids
- C. Place the client in a supine position
- D. Administer epinephrine
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.
A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?
- A. Administering pain medication
- B. Performing a head-to-toe assessment
- C. Establishing an intravenous line
- D. Administering oxygen
Correct Answer: D
Rationale: Correct Answer: D - Administering oxygen
Rationale:
1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload.
2. Administering oxygen helps alleviate ischemia and prevents further damage.
3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being.
Summary of other choices:
A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction.
B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation.
C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.
What is the most important nursing intervention for a client with severe dehydration?
- A. Administer IV fluids
- B. Monitor vital signs
- C. Provide oral rehydration
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.
A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?
- A. Ruddy blue
- B. Generalized pallor
- C. Ashen, grey, or dull
- D. Patchy areas of pallor
Correct Answer: C
Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion.
The other choices are incorrect because:
A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent.
B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock.
D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.