Nokea
How should signs of dehydration in an elderly patient be assessed?
- A. Monitor skin turgor
- B. Check for dry mucous membranes
- C. Monitor for sunken eyes
- D. Check capillary refill
Correct Answer: A
Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.
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Which of the following is a sign of digoxin toxicity?
- A. Bradycardia
- B. Hypertension
- C. Tachycardia
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A, Bradycardia. Bradycardia, or a slower than normal heart rate, is a classic sign of digoxin toxicity. Digoxin is a medication commonly used to treat heart conditions, but an excess of digoxin in the body can lead to toxicity. This toxicity can manifest as various symptoms, with bradycardia being one of the most common ones. Hypertension (high blood pressure) and tachycardia (fast heart rate) are not typical signs of digoxin toxicity. Tachypnea, which refers to rapid breathing, is also not a common sign of digoxin toxicity.
A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct Answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.
A nurse is planning care for a client who has osteoarthritis. Which of the following interventions should the nurse include?
- A. Administer opioids routinely for chronic pain.
- B. Instruct the client to avoid weight-bearing exercises.
- C. Apply heat to affected joints to reduce stiffness.
- D. Avoid physical activity to prevent joint damage.
Correct Answer: C
Rationale: The correct intervention for a client with osteoarthritis is to apply heat to affected joints to reduce stiffness. Heat application helps improve circulation, relax muscles, and reduce discomfort in joints affected by osteoarthritis. Administering opioids routinely (Choice A) is not the first-line treatment for osteoarthritis and carries risks of dependency and side effects. Instructing the client to avoid weight-bearing exercises (Choice B) may lead to muscle weakness and reduced joint flexibility. Avoiding physical activity altogether (Choice D) can lead to further joint stiffness and compromised overall health.
A client has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime to prevent nausea.
- B. Take this medication with a full glass of milk.
- C. Notify your provider if you experience visual disturbances.
- D. Report any muscle pain to your provider.
Correct Answer: C
Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.
What is the primary nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Monitor vital signs
- D. Check oxygen saturation
Correct Answer: A
Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.