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How should a healthcare professional respond to a patient who is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Encourage deep breathing exercises
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.
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A client with a colostomy needs optimal skin integrity. What action should the nurse take to promote this?
- A. Cleanse the peristomal skin with alcohol.
- B. Change the colostomy pouch every 3 days.
- C. Use a barrier cream to protect the skin from the pouch contents.
- D. Cleanse the stoma with hydrogen peroxide.
Correct Answer: C
Rationale: To promote optimal skin integrity in a client with a colostomy, using a barrier cream to protect the skin from the irritating effects of the colostomy pouch contents is essential. Cleansing the peristomal skin with alcohol (Choice A) can be too harsh and drying for the skin. Changing the colostomy pouch every 3 days (Choice B) is important for hygiene but using a barrier cream is more directly related to skin protection. Cleaning the stoma with hydrogen peroxide (Choice D) is not recommended as it can be too abrasive for the sensitive stoma area.
What is the best nursing action for a patient experiencing shortness of breath?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide IV fluids
Correct Answer: A
Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.
Which lab value should be monitored in patients receiving furosemide?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor glucose levels
Correct Answer: A
Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.
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.
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.