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How should a healthcare professional monitor a patient for infection post-surgery?
- A. Monitor the surgical site
- B. Monitor for fever
- C. Check blood pressure
- D. Check for redness
Correct Answer: A
Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.
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A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?
- A. Carrots
- B. Cottage cheese
- C. Bananas
- D. Broccoli
Correct Answer: D
Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.
A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Increased appetite
- B. Dry mucous membranes
- C. Hypotension
- D. Hyperreflexia
Correct Answer: C
Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.
A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypoglycemia
- C. Diaphoresis
- D. Tachycardia
Correct Answer: A
Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.
What is the most appropriate action when a patient experiences chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Reposition the patient
- D. Prepare for surgery
Correct Answer: A
Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.
What is the most important nursing intervention for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Provide supplemental oxygen
- C. Start IV fluids
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators. During an acute asthma attack, bronchodilators like albuterol are crucial to help dilate the airways and improve breathing. Providing supplemental oxygen (Choice B) may be necessary but is not the priority intervention. Starting IV fluids (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of care but are not the most critical interventions during an acute asthma attack.