Nokea
How should a healthcare provider monitor a patient with fluid overload?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor input and output
- D. Monitor blood pressure
Correct Answer: A
Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.
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What is the appropriate nursing intervention for a patient experiencing a suspected stroke?
- A. Administer thrombolytics
- B. Perform a neurological assessment
- C. Perform a CT scan
- D. Administer oxygen
Correct Answer: B
Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administration of acetaminophen
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.
What is the appropriate diet for a patient with chronic kidney disease?
- A. Low protein diet
- B. High protein diet
- C. Low sodium diet
- D. Low potassium diet
Correct Answer: A
Rationale: A low protein diet is the appropriate choice for a patient with chronic kidney disease because it helps to reduce the buildup of waste products in the body, which the kidneys may struggle to filter out. High protein diets can put extra strain on the kidneys by increasing the workload to eliminate the byproducts of protein metabolism. While low sodium and low potassium diets can also be important for managing certain aspects of kidney disease, the primary focus should be on controlling protein intake to lessen the burden on the kidneys.
How should bleeding in a patient on warfarin be monitored?
- A. Monitor INR levels
- B. Monitor hemoglobin levels
- C. Monitor potassium levels
- D. Monitor platelet count
Correct Answer: A
Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse plan to administer?
- A. Lorazepam
- B. Atenolol
- C. Naltrexone
- D. Methadone
Correct Answer: A
Rationale: Lorazepam is the correct choice for managing acute alcohol withdrawal symptoms due to its effectiveness in controlling agitation and tremors associated with this condition. Atenolol (Choice B) is a beta-blocker mainly used for hypertension and angina, not for alcohol withdrawal symptoms. Naltrexone (Choice C) is used for alcohol dependence treatment by reducing cravings and the rewarding effects of alcohol, but it is not typically used in acute withdrawal situations. Methadone (Choice D) is an opioid agonist mainly used for opioid detoxification and maintenance therapy, not for alcohol withdrawal.