Nokea
An Aboriginal woman who lives away from the reserve has come to the clinic to seek help with regulating her diabetes. In conducting an interview, the nurse's priority involves:
- A. finding out why the patient is not compliant.
- B. reinforcing the health teaching related to diet and exercise.
- C. determining if the patient can afford her medications.
- D. sending the patient to the diabetic clinic for follow-up.
Correct Answer: C
Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications.
A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.
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A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:
- A. "Can you tell me what they look like?"
- B. "Don't worry about it. You are only taking two."
- C. "How long have you been taking each of these pills?"
- D. "Would you ask your family to bring in your medications?"
Correct Answer: D
Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being. Choice A is incorrect as appearance alone may not provide accurate information. Choice B is dismissive and does not address the issue. Choice C focuses on duration rather than addressing the immediate concern of medication identification.
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hyperglycemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Anemia.
- D. Hyperglycemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.
A nurse is caring for a patient who is post-operative following hip replacement surgery. Which of the following should be included in the nursing care plan to prevent complications?
- A. Encouraging the patient to avoid physical activity for several weeks.
- B. Administering pain medication only when requested by the patient.
- C. Monitoring the patient for signs of infection and deep vein thrombosis.
- D. Providing education on safe lifting techniques.
Correct Answer: C
Rationale: The correct answer is C because monitoring the patient for signs of infection and deep vein thrombosis is crucial in preventing complications post-hip replacement surgery. Infections can lead to serious complications, while deep vein thrombosis can result in blood clots that can be life-threatening. By closely monitoring for these signs, the nurse can intervene early and prevent further complications.
Choice A is incorrect because complete avoidance of physical activity can lead to other complications such as muscle atrophy and delayed recovery. Choice B is incorrect because pain management should be proactive to prevent unnecessary suffering. Choice D, while important, is not directly related to preventing complications such as infection and deep vein thrombosis.
A nurse is caring for a patient who is post-operative following hip replacement surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication regularly.
- B. Encouraging early ambulation.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.