Nokea
How should a healthcare provider manage a patient with dehydration?
- A. Monitor fluid intake
- B. Encourage oral rehydration
- C. Administer IV fluids
- D. All of the above
Correct Answer: D
Rationale: Dehydration management involves a comprehensive approach that includes monitoring fluid intake to assess the severity of dehydration, encouraging oral rehydration to replenish fluids orally if the patient can tolerate it, and administering IV fluids in severe cases where oral intake is insufficient. Choosing just one of these options may not address the diverse needs of patients with dehydration. Therefore, selecting 'All of the above' is the most appropriate response as it encompasses the various strategies required for effective dehydration management.
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A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Position the drainage bag below the bladder
- B. Wipe the drainage port after emptying
- C. Insert the catheter using sterile technique
- D. Avoid cleansing the urinary meatus
Correct Answer: B
Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.
Which nursing action is a priority when caring for a client with heart failure?
- A. Encourage the client to drink fluids frequently
- B. Weigh the client daily to monitor fluid balance
- C. Increase fluid intake to prevent dehydration
- D. Limit the client's sodium intake
Correct Answer: B
Rationale: Weighing the client daily is a priority action when caring for a client with heart failure because it helps monitor fluid balance. This monitoring is essential in managing heart failure as it allows healthcare providers to assess for signs of fluid retention or depletion, which are crucial in adjusting treatment plans. Encouraging the client to drink fluids frequently (Choice A) may worsen fluid overload in heart failure patients. Increasing fluid intake (Choice C) can exacerbate fluid retention. While limiting sodium intake (Choice D) is important in heart failure management, monitoring fluid balance through daily weighing takes precedence as a priority nursing action.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
- A. Take the client to the dining room with 1:1 supervision
- B. Inform the client they may go to the dining room when they control their behavior
- C. Hold the meal until the client is able to come out of seclusion
- D. Serve the meal to the client in the seclusion room
Correct Answer: D
Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.
What is the first step when administering a blood transfusion?
- A. Warm the blood to body temperature
- B. Verify the client's blood type before administration
- C. Administer the blood through an IV push
- D. Administer diuretics before the transfusion
Correct Answer: B
Rationale: The correct answer is to verify the client's blood type before administration. This step is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Warming the blood to body temperature (Choice A) is not the first step and is not typically done during blood transfusions. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow infusion. Administering diuretics before the transfusion (Choice D) is unnecessary and not a standard practice when initiating a blood transfusion.
A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?
- A. Take the medication with food
- B. Avoid taking aspirin
- C. Schedule a bone density test
- D. Expect increased appetite
Correct Answer: C
Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).