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A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
- A. Oxygen saturation levels.
- B. Pain levels.
- C. Bowel sounds.
- D. Level of consciousness.
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
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A patient is diagnosed with anemia. The nurse is educating the patient about dietary sources of iron. Which of the following foods is the best source of iron?
- A. Eggs.
- B. Spinach.
- C. Chicken liver.
- D. Oranges.
Correct Answer: C
Rationale: The correct answer is C: Chicken liver. Chicken liver is the best source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods like spinach or oranges. Eggs do contain iron, but in smaller amounts compared to chicken liver. Oranges, on the other hand, are a source of vitamin C which can enhance iron absorption but do not contain significant amounts of iron themselves.
A patient with heart failure is experiencing shortness of breath, fatigue, and swelling in the legs. The nurse should monitor for signs of which of the following complications?
- A. Pulmonary embolism.
- B. Renal failure.
- C. Liver failure.
- D. Worsening heart failure.
Correct Answer: D
Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pulmonary embolism.
- B. Pneumothorax.
- C. Hypercapnia.
- D. Asthma attack.
Correct Answer: C
Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure.
Incorrect choices:
A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD.
B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication.
D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.
A nurse is frequently bothered when a patient does not take the medications as prescribed until the patient speaks with her family. The nurse is so irritated by this behaviour that he often finds it hard to provide appropriate care to this individual. What should the nurse do first in trying to overcome his difficulty?
- A. Identify the meaning of family inclusion to the patient
- B. Understand that this is a cultural practice that is helpful to the patient
- C. Allow the patient to take her medications only when she feels comfortable
- D. Discuss with the patient the importance of independent health decisions
Correct Answer: B
Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.
A nurse is caring for a patient with a history of chronic asthma. The nurse should prioritize monitoring for which of the following complications?
- A. Pneumothorax.
- B. Hyperglycemia.
- C. Respiratory failure.
- D. Chronic renal failure.
Correct Answer: C
Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.