Nokea
A nursing intervention for anemia is:
- A. Medical therapy
- B. High protein, vitamin and iron diet
- C. Fluid therapy
- D. Chemotherapy
Correct Answer: B
Rationale: Anemia is a condition characterized by a low red blood cell count or insufficient hemoglobin levels, resulting in decreased oxygen-carrying capacity in the blood. One of the nursing interventions for anemia is to promote a high protein, vitamin, and iron diet. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. Including foods rich in iron, such as lean meats, dark leafy greens, beans, and fortified cereals, can help boost iron levels in the body. Additionally, consuming foods high in vitamin C can also aid in iron absorption. Protein is crucial for overall health and plays a role in red blood cell production. By encouraging a nutrient-rich diet, nurses can help support the body's ability to replenish its red blood cell supply and improve the symptoms associated with anemia.
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Which of the following may be the first abnormal sign detected in a client with cardiomyopathy?
- A. Ascites c.Chest pain
- B. Heart murmur
- C. Dyspnea
Correct Answer: C
Rationale: Dyspnea, or difficulty breathing, may be the first abnormal sign detected in a client with cardiomyopathy. Cardiomyopathy is a disease of the heart muscle, which can lead to impaired heart function. As the heart's ability to pump blood effectively is compromised, the body may not receive an adequate supply of oxygen-rich blood. This can result in symptoms such as dyspnea, especially during physical exertion or when lying down. Ascites (fluid accumulation in the abdomen), chest pain, and heart murmur may also be seen in clients with cardiomyopathy but are not typically the first signs to present. Dyspnea is often a key indicator that should prompt further evaluation and monitoring for cardiac issues.
When caring for a 3 year old with tetralogy of Fallot, he nurse expects to see fatigue and poor activity tolerance. This is caused by:
- A. Poor muscle tone
- B. Inadequate oxygenation of tissues.
- C. Restricted blood flow leaving the heart
- D. Inadequate intake of food.
Correct Answer: B
Rationale: Tetralogy of Fallot is a heart defect that involves four specific abnormalities in the heart's structure. One of these abnormalities is a ventricular septal defect, which results in a mixing of oxygenated and deoxygenated blood. This leads to inadequate oxygenation of tissues because some of the blood that is pumped out to the body is not fully oxygenated. As a result, the child may experience fatigue and poor activity tolerance due to the reduced oxygen supply to the tissues and organs. This is why the nurse would expect to see these symptoms in a 3-year-old with tetralogy of Fallot.
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: An adult with a central venous line should include monitoring for any signs of infection, air embolus, and leakage or puncture in the plan of care. Central venous lines carry a risk of complications such as infection, air embolism, and mechanical issues like leakage or puncture. These complications can be serious and require immediate attention to prevent further harm to the patient. Regular monitoring and assessment for these potential issues are crucial in providing safe care for a patient with a central venous line. Other options (A, B, C) may be important in the overall care but monitoring for complications is the priority.
A nurse approaches a hospitalized poststroke patient from the patient's left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse's presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient's face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: The nurse should walk to the other side of the bed and approach the patient from the right side. Poststroke patients may have neglect syndrome, which can cause them to ignore stimuli on one side of their body. By approaching from the neglected side (the right side in this case), the nurse may be able to better capture the patient's attention and engage them in the assessment process. It is essential to adapt care to accommodate the patient's condition and ensure effective communication and interaction.
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: Strawberries are a common allergen and can cause allergic reactions in some individuals. Allergies to strawberries are relatively common and can present as mild reactions like itching and hives, or more severe symptoms such as difficulty breathing and anaphylaxis. It is important for healthcare professionals, such as nurses, to be aware of common allergens when taking a dietary history from clients to ensure their safety and well-being.