Nokea
How should a healthcare professional manage a patient with respiratory distress?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Check oxygen saturation
- D. Reposition the patient
Correct Answer: B
Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.
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What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?
- A. Respect the patient's decision and notify the provider
- B. Attempt to persuade the patient to accept the transfusion
- C. Document the refusal and notify the healthcare provider
- D. Provide education on the benefits of blood transfusion
Correct Answer: A
Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.
A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?
- A. I will need to increase my intake of leafy green vegetables.
- B. I will avoid drinking grapefruit juice while taking warfarin.
- C. I will have my INR checked regularly.
- D. I will take my medication at the same time each day.
Correct Answer: C
Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.
Which of the following is the most concerning electrolyte imbalance for a patient on furosemide?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is Hypokalemia. Furosemide, a loop diuretic, can lead to potassium depletion in the body, causing hypokalemia. This is a significant concern as low potassium levels can result in cardiac arrhythmias and other serious complications. Hyperkalemia (Choice B) is unlikely to occur as a result of furosemide use. Hyponatremia (Choice C) is more commonly associated with thiazide diuretics. Hypercalcemia (Choice D) is not typically linked to furosemide use.
A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?
- A. Inject air into the vial before withdrawing the insulin.
- B. Draw up the short-acting insulin first, then the long-acting insulin.
- C. Store unopened insulin vials in the freezer.
- D. Rotate injection sites within the same anatomical region.
Correct Answer: D
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.
A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?
- A. Encourage the client to increase fluid intake.
- B. Suction the client every 2 hours.
- C. Perform chest physiotherapy every 8 hours.
- D. Administer oxygen via nasal cannula.
Correct Answer: A
Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.