Nokea
How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
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What is the priority intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Prepare for surgery
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Administering oxygen is the priority intervention for a patient with a suspected pulmonary embolism to improve oxygenation levels. In pulmonary embolism, there is a blockage in one of the pulmonary arteries, leading to decreased oxygen exchange. Administering oxygen helps increase oxygen saturation levels. Anticoagulants (Choice B) are essential in the treatment of pulmonary embolism but are not the initial priority intervention. Surgery (Choice C) is not typically the first-line treatment for pulmonary embolism. Monitoring oxygen saturation (Choice D) is important but administering oxygen takes precedence as the immediate action to address hypoxemia.
A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?
- A. The client's urine output decreases.
- B. The client's blood pressure increases.
- C. The client's heart rate increases.
- D. The client's urine specific gravity decreases.
Correct Answer: A
Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.
While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?
- A. Ensure the eye shield is covering the eyes.
- B. Apply lotion to the exposed skin.
- C. Offer glucose water between feedings.
- D. Discontinue breastfeeding during treatment.
Correct Answer: A
Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.
A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct Answer: A
Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.
A client has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime to prevent nausea.
- B. Take this medication with a full glass of milk.
- C. Notify your provider if you experience visual disturbances.
- D. Report any muscle pain to your provider.
Correct Answer: C
Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.