Nokea
How should a healthcare professional manage a patient with a suspected stroke?
- A. Monitor for changes in neurological status and administer thrombolytics
- B. Monitor for speech difficulties and administer oxygen
- C. Provide IV fluids and monitor blood pressure
- D. Administer pain relief and monitor for respiratory failure
Correct Answer: A
Rationale: Corrected Rationale: When managing a patient with a suspected stroke, it is crucial to monitor for changes in neurological status as this can provide important information about the patient's condition. Administering thrombolytics, if indicated, is a critical intervention in the acute phase of an ischemic stroke to help dissolve blood clots and restore blood flow to the brain. This choice is the correct answer because it addresses the immediate management needs of a patient with a suspected stroke. Choices B, C, and D are incorrect because while monitoring for speech difficulties, administering oxygen, providing IV fluids, monitoring blood pressure, administering pain relief, and monitoring for respiratory failure are important aspects of patient care, they are not the primary interventions for managing a suspected stroke.
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A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Position the drainage bag below the bladder
- B. Wipe the drainage port after emptying
- C. Insert the catheter using sterile technique
- D. Avoid cleansing the urinary meatus
Correct Answer: B
Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client's peripheral pulse rate every 30 minutes.
- C. Obtain a prescription for restraint within 4 hours.
- D. Document the client's condition every 15 minutes.
Correct Answer: D
Rationale: In a situation where a verbal prescription for restraints is obtained for a client experiencing acute mania, the nurse should document the client's condition every 15 minutes. This frequent documentation allows for accurate monitoring of the client's condition, ensuring safety and compliance. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is not directly related to the need for restraints in this scenario. Obtaining a prescription for restraint within 4 hours (Choice C) is not a priority when a verbal prescription is already obtained and immediate action is needed for the client's safety.
A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?
- A. Change the appliance daily
- B. Clean the stoma once a day
- C. Avoid changing the appliance for a week
- D. Change the appliance twice each week
Correct Answer: D
Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.
What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?
- A. Edema, weight gain, shortness of breath
- B. Fever, cough, chest pain
- C. Increased heart rate, low blood pressure
- D. Increased blood pressure, jugular venous distention
Correct Answer: A
Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.
How should a healthcare provider manage a patient with dehydration?
- A. Monitor fluid intake
- B. Encourage oral rehydration
- C. Administer IV fluids
- D. All of the above
Correct Answer: D
Rationale: Dehydration management involves a comprehensive approach that includes monitoring fluid intake to assess the severity of dehydration, encouraging oral rehydration to replenish fluids orally if the patient can tolerate it, and administering IV fluids in severe cases where oral intake is insufficient. Choosing just one of these options may not address the diverse needs of patients with dehydration. Therefore, selecting 'All of the above' is the most appropriate response as it encompasses the various strategies required for effective dehydration management.