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How should a healthcare provider respond to a patient experiencing acute chest pain?
- A. Administer prescribed nitroglycerin
- B. Provide oxygen
- C. Call for emergency assistance
- D. Reassure the patient
Correct Answer: A
Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.
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A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct Answer: B
Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct Answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
- A. Sit up for at least 30 minutes after eating
- B. Avoid fluids between meals
- C. Increase the intake of high-carbohydrate foods
- D. Avoid eating large meals that are high in simple sugars and liquids
Correct Answer: D
Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.
A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor daily fluid intake
- B. Monitor blood glucose levels
- C. Measure intake and output
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.
A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct Answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.