Nokea
What are the key interventions for managing pneumonia?
- A. Administer antibiotics and monitor oxygen levels
- B. Administer bronchodilators and encourage deep breathing
- C. Provide fluids and monitor for dehydration
- D. Administer oxygen and provide bed rest
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.
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What is the proper technique for measuring blood pressure manually?
- A. Use a stethoscope to listen for the Korotkoff sounds
- B. Ensure the patient is seated with the arm supported
- C. Use a manual sphygmomanometer
- D. Deflate the cuff slowly while listening to the heartbeat
Correct Answer: A
Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.
A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?
- A. Monitor the client's fluid and electrolyte balance
- B. Consult a dietitian to improve the client's nutritional status
- C. Administer a protein supplement
- D. Administer an anti-inflammatory medication
Correct Answer: B
Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.
What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?
- A. Monitor for changes in level of consciousness
- B. Check for pupil dilation
- C. Assess for bradycardia
- D. Monitor for vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.
What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?
- A. Administer insulin and fluids
- B. Administer oral hypoglycemics
- C. Administer glucagon
- D. Administer insulin and monitor blood glucose
Correct Answer: A
Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.
A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?
- A. Analgesic
- B. Antiplatelet
- C. Anticoagulant
- D. Thrombolytic
Correct Answer: B
Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.