Nokea
A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
- A. Leavened bread may be eaten during Passover.
- B. Shellfish is commonly consumed in the diet.
- C. Meat and dairy products are eaten separately.
- D. Fasting from meat occurs during Hanukkah.
Correct Answer: C
Rationale: The correct answer is C. Kosher dietary laws require the separation of meat and dairy products. Choice A is incorrect because leavened bread is not eaten during Passover in Jewish dietary practices. Choice B is incorrect as shellfish is not considered kosher and is not consumed in Jewish dietary practices. Choice D is incorrect as fasting from meat does not occur during Hanukkah.
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A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?
- A. Client placed in restraints due to aggressive behavior
- B. A new client with a history of 4.5 kg weight loss in the past two months
- C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
- D. Client receiving first ECT treatment today
Correct Answer: A
Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.
Which lab value should be monitored in a patient on digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor digoxin levels
- D. Monitor sodium levels
Correct Answer: C
Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.
What is the most important nursing action for a patient post-surgery?
- A. Monitor vital signs
- B. Monitor the surgical site
- C. Check blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.
How should a healthcare provider manage a patient with chronic heart failure?
- A. Monitor daily weight
- B. Provide fluid restriction
- C. Administer diuretics
- D. Monitor intake and output
Correct Answer: A
Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.
What is the best intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Reposition the patient
- D. Administer bronchodilators
Correct Answer: A
Rationale: Administering oxygen is the best intervention for a patient with a suspected pulmonary embolism because it helps alleviate respiratory distress and improve oxygenation. Oxygen therapy is crucial to ensure adequate oxygen levels in the blood due to the obstruction in the pulmonary circulation caused by the embolism. Administering anticoagulants (choice B) is a treatment for confirmed pulmonary embolism rather than a suspected case. Repositioning the patient (choice C) or administering bronchodilators (choice D) would not directly address the underlying issue of impaired gas exchange and oxygen delivery associated with pulmonary embolism.