Nokea
In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.
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In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
- A. Complete set of vital signs
- B. Palpation and auscultation of the abdomen
- C. Brief neurologic assessment
- D. Initiation of pulse oximetry
Correct Answer: C
Rationale: A brief neurologic assessment helps quickly identify potential brain injuries or other neurological deficits.
A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?
- A. The importance of regular exercise
- B. Proper administration of insulin
- C. Maintaining a low-carbohydrate diet
- D. Recognizing signs of hyperglycemia
Correct Answer: B
Rationale: The correct answer is B, proper administration of insulin, because it is crucial for managing type 1 diabetes. Insulin is essential for regulating blood sugar levels in type 1 diabetes patients. Without proper insulin administration, the client's condition can deteriorate rapidly. Regular exercise (A) and a low-carbohydrate diet (C) are important aspects of diabetes management, but they are not as critical as ensuring proper insulin administration. Recognizing signs of hyperglycemia (D) is important, but knowing how to administer insulin correctly takes precedence in effectively managing type 1 diabetes.
After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?
- A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
- B. Client's HR is 55 beats/min. Nurse withholds pain medication.
- C. Client has reduced breath sounds. Nurse calls the physician immediately.
- D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.
Correct Answer: C
Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment.
Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.
Identify the options for communication with each type of client: A client who has suffered a stroke, has expressive aphasia, and has lost use of their dominant hand.
- A. Use written communication and visual aids.
- B. Ask a family member to interpret.
- C. Speak louder and slower.
- D. Use sign language.
Correct Answer: A
Rationale: Written communication and visual aids help bridge the gap caused by expressive aphasia and physical limitations.
The best treatment for mononucleosis is
- A. Antibiotics.
- B. Physical therapy.
- C. Nonsteroidal anti-inflammatory drugs (NSAIDs).
- D. Rest and fluids.
Correct Answer: D
Rationale: Rest and hydration are the mainstays of treatment for mononucleosis.