Nokea
What are the priority nursing interventions for a client in shock?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.
You may also like to solve these questions
When assessing a client with anxiety disorder, what does the nurse observe for evidence of various levels of anxiety?
- A. Absence of crying
- B. Talking excessively
- C. Being motionless
- D. Not complaining
Correct Answer: B
Rationale: Excessive talking may indicate heightened anxiety as the client attempts to distract themselves from their worries.
Mary Thomas presents with red, teary eyes, a runny nose, and a stuffy head. What nursing orders would be recommended?
- A. Antihistamines, aspirin, and cough syrup
- B. Increased fluids, steam inhalation, and rest
- C. Aspirin, cough syrup, and increased fluids
- D. Auscultation and percussion of the chest
Correct Answer: B
Rationale: Hydration, steam inhalation, and rest help alleviate symptoms and promote recovery.
A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like information about advance directives?
- B. I will arrange for a psychiatrist to speak with you.
- C. Do you want to come off the transplant list?
- D. Would you like to speak with a priest or chaplain?
Correct Answer: A
Rationale: The correct answer is A: Would you like information about advance directives? This is the appropriate response as it addresses the client's concerns about becoming a vegetable and explores their wishes for end-of-life care. Advance directives can help the client make decisions about their care in case they are unable to communicate in the future. The other choices are incorrect because B assumes the client needs psychiatric evaluation, C suggests removing them from the transplant list without exploring their concerns further, and D focuses on spiritual support rather than addressing the client's specific worries about their quality of life post-transplant.
What information in Mr. Singer’s history is most likely associated with his diagnosis of cancer of the larynx?
- A. Shortness of breath on exertion
- B. Abdominal distention
- C. Alteration in voice
- D. Loss of appetite
Correct Answer: C
Rationale: Hoarseness or voice changes are early signs of laryngeal cancer.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.