Nokea
How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct Answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
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A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?
- A. Remove the weights
- B. Ensure the weights hang freely
- C. Increase the traction force
- D. Loosen the ropes
Correct Answer: B
Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will position the car seat in the front seat
- B. I will secure the car seat in the car by using the seatbelt
- C. I will use a rear-facing car seat
- D. I will install the car seat facing forward
Correct Answer: C
Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.
What are the risk factors for developing hypertension?
- A. High sodium diet and lack of physical activity
- B. Low potassium intake and excessive alcohol consumption
- C. Frequent exercise and low cholesterol diet
- D. Smoking and family history
Correct Answer: A
Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.
A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?
- A. Irrigate the wound with normal saline.
- B. Apply a wet-to-dry gauze dressing.
- C. Use a cotton ball to cleanse the wound.
- D. Administer an analgesic after the dressing change.
Correct Answer: A
Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.
A nurse is teaching a client who has Parkinson's disease about dietary modifications. Which of the following instructions should the nurse include?
- A. Eat high-protein, high-calorie meals
- B. Drink milk with every meal
- C. Avoid foods high in carbohydrates
- D. Drink carbonated beverages with meals
Correct Answer: A
Rationale: The correct answer is A: 'Eat high-protein, high-calorie meals.' Individuals with Parkinson's disease benefit from consuming high-protein, high-calorie meals to help maintain muscle mass and energy levels. This dietary modification is important in managing the symptoms of Parkinson's disease. Choice B is incorrect because there is no specific requirement for drinking milk with every meal for individuals with Parkinson's disease. Choice C is incorrect as carbohydrates are also essential for a balanced diet and should not be completely avoided. Choice D is incorrect as carbonated beverages may interfere with the absorption of nutrients from food and are not recommended for individuals with Parkinson's disease.