Nokea
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
- A. Severe pain and nausea.
- B. Uncontrolled symptoms despite treatment.
- C. Psychosocial support needs.
- D. All of the above.
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.
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Which of the following actions is the nurse's priority when caring for a client with a head injury?
- A. Monitor the client's airway
- B. Administer pain relief
- C. Perform a CT scan
- D. Monitor intracranial pressure
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's airway. This is the priority because airway management is crucial in ensuring adequate oxygenation and ventilation, which is essential for brain function in a client with a head injury. Maintaining a clear airway takes precedence over other actions such as administering pain relief, performing a CT scan, or monitoring intracranial pressure. While these actions are important, ensuring the client's airway is patent and adequate oxygenation is crucial for preventing further brain injury or complications.
What is the most appropriate intervention for serosanguineous drainage after cholecystectomy?
- A. notify the physician of the drainage
- B. change the dressing
- C. reinforce the dressing
- D. apply an abdominal binder
Correct Answer: C
Rationale: Rationale:
C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.
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.
What is the first action the nurse should take when a client presents with signs of respiratory distress?
- A. Open the airway
- B. Administer oxygen
- C. Administer medication
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.
While obtaining the history from the mother of a 2-year-old with pneumonia, the nurse asks the mother if she smoked or used drugs during her pregnancy. Her response is, "What does that have to do with pneumonia?" How would the nurse answer her question?
- A. "You don't need to answer if it makes you uncomfortable."
- B. "It's not really that important; we have to ask everyone these questions."
- C. "The use of tobacco during your pregnancy could be the cause of your daughter's pneumonia."
- D. "Knowing about your pregnancy will help us get a more complete picture of your daughter's health."
Correct Answer: D
Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions.
Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.