Nokea
A patient with heart failure tells the nurse, "I can't breathe very well at night." The nurse should ask:
- A. "Is the breathing difficulty worse when you're lying down?"
- B. "What has been the duration of your breathing problems?"
- C. "Do you feel short of breath during the day as well?"
- D. "Have you had any previous episodes of difficulty breathing?"
Correct Answer: A
Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.
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Which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.
Which organ is responsible for the extensive metabolism of acetaminophen?
- A. Liver
- B. Kidneys
- C. Lungs
- D. Pancreas
Correct Answer: A
Rationale: The correct answer is A: Liver. The liver is responsible for the extensive metabolism of acetaminophen through various pathways, including glucuronidation, sulfation, and oxidation. It converts acetaminophen into less toxic metabolites for elimination. The kidneys (B) primarily filter blood and regulate fluid balance; the lungs (C) are involved in gas exchange; and the pancreas (D) produces digestive enzymes and insulin, not involved in acetaminophen metabolism. Therefore, the liver is the correct choice for this question.
What is the most important intervention for a client with acute myocardial infarction (MI)?
- A. Administer aspirin
- B. Administer oxygen
- C. Administer morphine
- D. Administer nitroglycerin
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.
A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for which of the following complications?
- A. Neutropenia.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Chronic pain.
Correct Answer: A
Rationale: The correct answer is A: Neutropenia. During chemotherapy, neutropenia, a decrease in white blood cells, can occur, leading to increased risk of infections. Monitoring for neutropenia is crucial for timely intervention. Hyperkalemia (B) is not commonly associated with chemotherapy. Hypoglycemia (C) is more related to diabetes or insulin therapy. Chronic pain (D) is not a typical complication of chemotherapy. Monitoring for neutropenia allows the nurse to provide appropriate care to prevent infections and ensure the patient's safety.
What is the most important intervention when caring for a client with suspected pneumonia?
- A. Administer IV antibiotics
- B. Administer pain medications
- C. Administer antiemetics
- D. Administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer IV antibiotics. Administering IV antibiotics is crucial in treating pneumonia as it helps combat the underlying bacterial infection causing pneumonia. Prompt antibiotic therapy can prevent complications and improve patient outcomes. Administering pain medications (B) may help manage symptoms but does not address the root cause. Administering antiemetics (C) may help with nausea and vomiting but does not directly treat pneumonia. Option D is similar to the correct answer but lacks the specificity of IV antibiotics, which are often preferred for severe cases.