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A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.
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A patient with gout is prescribed allopurinol. What should the nurse include in the patient teaching?
- A. Take the medication with food.
- B. Increase intake of high-purine foods.
- C. Limit fluid intake to 1 liter per day.
- D. Expect immediate pain relief.
Correct Answer: A
Rationale: The correct answer is A: Take the medication with food. Allopurinol can cause stomach upset, so taking it with food can help minimize gastrointestinal side effects. Taking it on an empty stomach may increase the risk of nausea or stomach pain. Choice B is incorrect because increasing high-purine foods can exacerbate gout symptoms. Choice C is incorrect because limiting fluid intake can lead to dehydration, which is not recommended for gout patients. Choice D is incorrect because allopurinol does not provide immediate pain relief; it works to lower uric acid levels over time to prevent gout attacks.
What is the primary cause of jaundice in a client with liver cirrhosis?
- A. Decreased bile production
- B. Increased bilirubin levels
- C. Hepatic inflammation
- D. Portal hypertension
Correct Answer: B
Rationale: The primary cause of jaundice in a client with liver cirrhosis is increased bilirubin levels. Liver cirrhosis impairs the liver's ability to process bilirubin, leading to its accumulation in the bloodstream. This excess bilirubin then causes the yellow discoloration of the skin and eyes characteristic of jaundice.
Incorrect Choices:
A: Decreased bile production is not the primary cause of jaundice in liver cirrhosis. While decreased bile flow may contribute to jaundice, it is secondary to the impaired bilirubin processing.
C: Hepatic inflammation is a common feature of liver cirrhosis but is not the direct cause of jaundice in this context.
D: Portal hypertension is a complication of liver cirrhosis but is not the primary cause of jaundice.
A patient with a myocardial infarction (MI) is being treated with intravenous morphine. What is the primary reason for administering morphine to this patient?
- A. To reduce pain.
- B. To decrease anxiety.
- C. To reduce cardiac workload.
- D. To increase respiratory rate.
Correct Answer: C
Rationale: The primary reason for administering morphine to a patient with MI is to reduce cardiac workload. Morphine acts as a vasodilator and decreases preload and afterload on the heart, reducing myocardial oxygen demand. This helps to improve coronary blood flow and decrease the workload on the heart muscle, which is crucial in the setting of an MI.
Explanation for other choices:
A: While morphine can help reduce pain in MI, the primary reason for administering it is to reduce cardiac workload.
B: Morphine may have a calming effect, but the primary goal is to reduce cardiac workload.
D: Morphine can actually decrease respiratory rate as a side effect, making this choice incorrect.
A patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include in the patient teaching?
- A. Take folic acid supplements as prescribed.
- B. Avoid alcohol completely.
- C. Expect to see immediate results.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: A
Rationale: The correct answer is A: Take folic acid supplements as prescribed. Methotrexate can lead to folic acid deficiency, so supplementing with folic acid helps prevent side effects. It is important for the nurse to educate the patient on the importance of taking folic acid to maintain overall health.
Choice B is incorrect. While it is generally recommended to limit alcohol consumption with methotrexate, avoiding it completely may not be necessary for all patients.
Choice C is incorrect. Methotrexate takes time to work, often several weeks to months, so immediate results should not be expected.
Choice D is incorrect. Limiting fluid intake to 1 liter per day is not a standard recommendation for patients taking methotrexate. Adequate hydration is important for overall health.
A patient who is receiving chemotherapy for breast cancer develops thrombocytopenia. What should the nurse include in the care plan?
- A. Encourage light exercise.
- B. Avoid intramuscular injections.
- C. Do not administer aspirin.
- D. Use a soft toothbrush for oral care.
Correct Answer: B
Rationale: The correct answer is B: Avoid intramuscular injections. Thrombocytopenia is a condition characterized by low platelet count, which can lead to impaired blood clotting. Intramuscular injections can cause bleeding and bruising due to the decreased ability of blood to clot. Therefore, it is crucial to avoid invasive procedures like intramuscular injections to prevent excessive bleeding in patients with thrombocytopenia. Encouraging light exercise (choice A) can be beneficial for overall health but may not directly address the risk of bleeding. Avoiding aspirin (choice C) is important as it can further increase the risk of bleeding. Using a soft toothbrush for oral care (choice D) is a good practice, but it does not directly address the risk associated with intramuscular injections in patients with thrombocytopenia.