Nokea
How should a healthcare professional assess and manage a patient with delirium?
- A. Assess for confusion and reorient the patient
- B. Provide a quiet environment and administer sedatives
- C. Provide oxygen therapy and monitor vital signs
- D. Provide pain relief and monitor for signs of recovery
Correct Answer: A
Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.
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What is an early sign that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased oxygen saturation
Correct Answer: B
Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.
A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?
- A. Clamp the chest tube
- B. Maintain the drainage below the level of the chest
- C. Elevate the chest tube above chest level
- D. Avoid frequent dressing changes
Correct Answer: B
Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.
What are the nursing interventions for a patient with hypokalemia?
- A. Administer potassium supplements and monitor ECG
- B. Provide a high-sodium diet and monitor for hypertension
- C. Monitor for muscle weakness and provide dietary education
- D. Administer diuretics and provide oral fluids
Correct Answer: A
Rationale: The correct intervention for a patient with hypokalemia is to administer potassium supplements and monitor the ECG. Potassium supplements help correct the low potassium levels in the body, while ECG monitoring is essential to detect any cardiac arrhythmias associated with hypokalemia. Choice B is incorrect because a high-sodium diet would worsen hypokalemia by further depleting potassium levels. Choice C is incorrect as it only focuses on monitoring symptoms and providing dietary education, but does not address the immediate need to correct potassium levels. Choice D is also incorrect as administering diuretics would exacerbate hypokalemia by increasing potassium loss.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Increased speech
- B. Lack of sleep
- C. Agitation
- D. Poor concentration
Correct Answer: B
Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct Answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.