Nokea
What changes are seen in the skin during shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
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A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report?
- A. Repeated episodes of nausea and vomiting
- B. Complaints of pain associated with exertion
- C. Failure to eat all food on breakfast tray
- D. Client hair loss during morning bath
Correct Answer: A
Rationale: Nausea and vomiting can lead to metabolic alkalosis due to loss of gastric acid, making it important to report promptly to prevent acid-base imbalances.
A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.
Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.
The main goal of treatment for acute glomerulonephritis is to
- A. encourage activity.
- B. encourage high protein intake.
- C. maintain fluid balance.
- D. teach intermittent urinary catheterization.
Correct Answer: C
Rationale: Maintaining fluid balance is critical in managing acute glomerulonephritis due to potential fluid overload.
What is the priority nursing action for this patient?
- A. Obtain an order for a blood alcohol level
- B. Contact the family to obtain additional history and baseline information
- C. Administer naloxone (Narcan) 2-4 mg as ordered
- D. Administer IV fluid support with supplemental thiamine as ordered
Correct Answer: D
Rationale: Fluid support and thiamine administration address potential dehydration and nutritional deficits in intoxicated patients.
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.