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 an early sign that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased oxygen saturation
Correct Answer: B
Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.
A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?
- A. Irrigate the wound with normal saline.
- B. Apply a wet-to-dry gauze dressing.
- C. Use a cotton ball to cleanse the wound.
- D. Administer an analgesic after the dressing change.
Correct Answer: A
Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.
What is the role of a nurse in managing a patient with acute kidney injury (AKI)?
- A. Monitor urine output and electrolyte levels
- B. Administer diuretics and restrict potassium
- C. Provide dietary education and monitor fluid intake
- D. Administer antibiotics and check for dehydration
Correct Answer: A
Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.
A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?
- A. Increase your intake of red meat
- B. Increase physical activity to 150 minutes per week
- C. Avoid foods high in fiber
- D. Increase sodium intake to 2,300 mg per day
Correct Answer: B
Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?
- A. Monitor the client's electrolyte levels
- B. Change the TPN tubing every 24 hours
- C. Monitor blood glucose levels every 4 hours
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B. Changing the TPN tubing every 24 hours is crucial in preventing infection by reducing the risk of bacterial contamination. Monitoring electrolyte levels (choice A) is essential but not directly related to preventing TPN-related infections. Monitoring blood glucose levels (choice C) is important for clients receiving TPN, but it is more related to glycemic control than infection prevention. Administering insulin as prescribed (choice D) is necessary for clients with diabetes but is not directly linked to preventing TPN-related infections.