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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.
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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 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 nurse is caring for a patient who is post-operative following a hip replacement. The nurse should educate the patient to avoid which of the following to prevent hip dislocation?
- A. Crossing the legs at the knees.
- B. Sitting with the feet flat on the floor.
- C. Sleeping on the affected side.
- D. Using assistive devices for ambulation.
Correct Answer: A
Rationale: The correct answer is A: Crossing the legs at the knees. This position can cause hip dislocation due to the twisting motion it creates on the hip joint. When the legs are crossed at the knees, it puts stress on the hip joint, potentially leading to dislocation.
Choice B: Sitting with the feet flat on the floor is a safe position that does not put undue stress on the hip joint.
Choice C: Sleeping on the affected side can also increase the risk of hip dislocation due to the pressure and weight placed on the hip joint in this position.
Choice D: Using assistive devices for ambulation is important for stability and support, and it does not directly contribute to hip dislocation if used correctly.
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.
The nurse is performing a review of systems on a 76-year-old patient. Which of the following statements is correct for this situation?
- A. The questions asked are identical for all ages.
- B. The interviewer will start incorporating different questions for patients 70 years of age and older.
- C. Additional questions are reflective of the normal effects of aging.
- D. At this age, a review of systems is not necessary; just focus on current problems.
Correct Answer: C
Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.