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How should a healthcare professional monitor a patient with a central line for infection?
- A. Monitor the dressing site daily
- B. Check for redness and swelling
- C. Monitor for fever
- D. Flush the central line
Correct Answer: A
Rationale: Monitoring the dressing site daily is crucial for detecting early signs of infection in patients with central lines. Checking for redness and swelling (choice B) is important but may indicate a more advanced stage of infection. Monitoring for fever (choice C) can also be a sign of infection, but it is a later manifestation. Flushing the central line (choice D) is necessary for maintaining patency but does not directly monitor for infection.
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A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 90/min
- B. Serum potassium level of 4.0 mEq/L
- C. Weight gain of 2 kg (4.4 lb) in 2 days
- D. Heart rate of 76/min
Correct Answer: C
Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.
A nurse is providing teaching to a client who has type 1 diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Trim your toenails straight across.
- D. Apply lotion to your feet after bathing.
Correct Answer: C
Rationale: The correct answer is C: 'Trim your toenails straight across.' Trimming toenails straight across helps prevent ingrown toenails, which is important for clients with diabetes to prevent infections. Choice A is incorrect because soaking feet in warm water can lead to skin breakdown and infections. Choice B is incorrect as cotton socks can retain moisture, increasing the risk of fungal infections. Choice D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of infections.
What is the appropriate action for a patient experiencing chest pain?
- A. Administer aspirin
- B. Reposition the patient
- C. Check oxygen saturation
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.
A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?
- A. Instruct the client to use an alcohol-free mouthwash.
- B. Apply heat packs to the radiation site.
- C. Provide a diet low in carbohydrates.
- D. Avoid exposure to direct sunlight during treatment.
Correct Answer: D
Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.
What is the correct method to teach a patient about self-administration of insulin?
- A. Inject into the upper arm
- B. Rotate injection sites
- C. Use a 45-degree angle for injection
- D. Use a 90-degree angle for injection
Correct Answer: D
Rationale: The correct method to teach a patient about self-administration of insulin is to use a 90-degree angle for injection. This angle ensures proper subcutaneous administration of insulin, which is essential for effective absorption. Injecting into the upper arm (Choice A) is not recommended for insulin administration. While rotating injection sites (Choice B) is important to prevent lipodystrophy, the angle of injection is crucial for proper insulin delivery. Using a 45-degree angle (Choice C) is more suitable for intramuscular injections, not for subcutaneous insulin injections.