Nokea
The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. “It will raise you BP, which is necessary because of blood loss.”
- B. “It will dilate your bronchioles and make your breathing easier.”
- C. “It will help your blood to clot to reduce bleeding.”
- D. “It will constrict your vessels and slow down the bleeding.”
Correct Answer: D
Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.
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An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
Which nursing interventions can help prevent falls in a patient with Parkinson’s disease? Choose all answers that are correct. i.Keep the patient’s call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient’s bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation
- A. 1, 4, 2005
- B. 1, 3, 4, 6
- C. 2, 3, 2006
- D. 2, 4, 5, 6
Correct Answer: A
Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position.
1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls.
2. Avoiding throw rugs prevents tripping hazards that can lead to falls.
3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed.
The incorrect choices:
- Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention.
- Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement.
- Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest
After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: A
Rationale: The correct answer is A: 30 minutes before breakfast. Glyburide is a sulfonylurea medication that stimulates insulin release from the pancreas, enhancing glucose uptake. Taking it before breakfast ensures peak insulin levels coincide with the postprandial glucose spike, aiding in glucose control throughout the day. Option B is incorrect as taking it after dinner may lead to hypoglycemia during sleep. Option C is incorrect as midmorning is not an optimal time for a sulfonylurea dose. Option D is incorrect as taking it at bedtime may also increase the risk of hypoglycemia overnight.
A nurse is collecting data from a home care client. In addition to information about the client’s health status, what is another observation the nurse should make?
- A. Number of rooms in the house
- B. Safety of the immediate environment
- C. Frequency of home visits to be made
- D. Friendliness of the client and family
Correct Answer: B
Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.
A client has type1 diabetes. Her husband finds her unconscious at home and administers glucagons, 0.5 mg S.C. She awakens in 5 minutes .Why her husband offer a complex carbohydrate snack to her as soon as possible?
- A. To decrease the possibility of nausea and vomiting
- B. To restore liver glycogen and prevent secondary hypoglycemia
- C. To stimulate her appetite
- D. To decrease the amount of glycogen in her system
Correct Answer: B
Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.