Nokea
Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should try to sleep more so you can take better care of your mother.
- C. Caring for a loved one at the end of life is very rewarding.
- D. It's important to stay strong for your mother during this time.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential interest in respite care, which can provide them with much-needed rest and support. This response shows empathy and offers a helpful solution. Choice B is incorrect as it oversimplifies the situation and places undue pressure on the caregiver. Choice C is incorrect as it may invalidate the caregiver's struggles and emotions, as caregiving can be overwhelming and challenging. Choice D is incorrect as it emphasizes the importance of strength without addressing the caregiver's need for support and self-care.
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Which action should the nurse include in the plan?
- A. Offer the client three large meals each day
- B. Provide small, frequent meals to reduce fatigue and improve intake.
- C. Encourage the client to drink fluids immediately before or after meals to prevent early satiety.
- D. Offer high-calorie, nutrient-dense foods to support weight maintenance.
- E. Monitor the client's weight regularly to assess nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Provide small, frequent meals to reduce fatigue and improve intake. This option is the most appropriate because small, frequent meals can help prevent fatigue and improve nutrient intake by ensuring a steady supply of energy throughout the day. Offering three large meals (option A) may overwhelm the client and lead to fatigue. Encouraging fluid intake before or after meals (option C) may cause early satiety and reduce food intake. Offering high-calorie, nutrient-dense foods (option D) can be beneficial, but the frequency of meals is more crucial in this scenario. Monitoring weight (option E) is important but does not directly address the issue of fatigue and intake.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
Which of the following actions should the nurse plan to take?
- A. Elevate the clients arm prior to insertion.
- B. Select a site on the client's dominant arm.
- C. Apply a tourniquet below the venipuncture site.
- D. Choose a vein that is palpable and straight.
Correct Answer: D
Rationale: The correct answer is D: Choose a vein that is palpable and straight. This is important because a palpable and straight vein ensures successful venipuncture and reduces the risk of complications such as infiltration or hematoma formation. Elevating the client's arm (A) may help visualize veins but does not guarantee choosing a suitable vein. Selecting a site on the client's dominant arm (B) is not necessary as both arms have suitable veins. Applying a tourniquet below the venipuncture site (C) can obstruct blood flow and distort the vein. Therefore, the best approach is to choose a vein that is palpable and straight for a successful venipuncture.
After administering naloxone, which finding should the nurse expect?
- A. Somnolence
- B. Increased respiratory rate
- C. Sudden onset of pain or discomfort
- D. Hypertension and tachycardia
- E. Nausea and vomiting
Correct Answer: B
Rationale: After administering naloxone, the nurse should expect an increased respiratory rate. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. By blocking opioid receptors, naloxone can restore normal breathing patterns. Choices A (Somnolence), C (Sudden onset of pain or discomfort), D (Hypertension and tachycardia), and E (Nausea and vomiting) are incorrect because they are not typical findings after administering naloxone. Somnolence would not be expected as naloxone counteracts sedation caused by opioids. Sudden onset of pain or discomfort is unrelated to naloxone administration. Hypertension and tachycardia are more indicative of opioid overdose, which naloxone would mitigate. Nausea and vomiting are also not common side effects of naloxone.
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Swelling of the face
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Swelling of the face. This finding could be indicative of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and organ damage. It is crucial to report this to the provider promptly to prevent complications. Bleeding gums (A) are common due to hormonal changes and increased blood flow, not typically a cause for concern. Faintness upon rising (B) is common in pregnancy due to low blood pressure but usually not a significant issue unless severe. Urinary frequency (D) is normal in pregnancy due to the growing uterus pressing on the bladder.