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What is the best intervention for a client who is vomiting after surgery?
- A. Administer antiemetics
- B. Place the client in a supine position
- C. Encourage deep breathing
- D. Administer morphine
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.
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A nurse is teaching a patient with a history of stroke about preventing future strokes. Which of the following statements by the patient indicates the need for further education?
- A. I will take my blood pressure medication regularly.
- B. I will limit my alcohol consumption.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will maintain a healthy diet and exercise regularly.
Correct Answer: C
Rationale: The correct answer is C because stopping medication once blood pressure is normal can lead to a rebound increase in blood pressure, increasing the risk of stroke. A patient with a history of stroke needs to continue taking medications as prescribed to maintain optimal blood pressure control. Statements A, B, and D are all indicative of good stroke prevention strategies, such as managing blood pressure, limiting alcohol intake, and maintaining a healthy lifestyle.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Pulmonary edema.
- C. Anemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function.
Rationale:
A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure.
C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema.
D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.
A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?
- A. Ruddy blue
- B. Generalized pallor
- C. Ashen, grey, or dull
- D. Patchy areas of pallor
Correct Answer: C
Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion.
The other choices are incorrect because:
A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent.
B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock.
D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
- A. I know that my name is John. I couldn't tell you where I am. I think this year is 2009, though.
- B. I know that my name is John, but to tell you the truth, I get kind of confused about the date.
- C. I know that my name is John; I guess I'm at the hospital in Victoria. No, I don't know the date.
- D. I know that my name is John. I am at the hospital in Victoria. I couldn't tell you what date it is, but I know that it is February of a new year"”2009.
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains.
Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.
When listening to a patient's breath sounds, the nurse is unsure about a sound that is hearThe nurse should:
- A. notify the patient's physician immediately.
- B. document the sound exactly as it was heard.
- C. validate the data by asking a colleague to listen to the breath sounds.
- D. assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.