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What is the best intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Reposition the patient
- D. Administer bronchodilators
Correct Answer: A
Rationale: Administering oxygen is the best intervention for a patient with a suspected pulmonary embolism because it helps alleviate respiratory distress and improve oxygenation. Oxygen therapy is crucial to ensure adequate oxygen levels in the blood due to the obstruction in the pulmonary circulation caused by the embolism. Administering anticoagulants (choice B) is a treatment for confirmed pulmonary embolism rather than a suspected case. Repositioning the patient (choice C) or administering bronchodilators (choice D) would not directly address the underlying issue of impaired gas exchange and oxygen delivery associated with pulmonary embolism.
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A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?
- A. Fatigue
- B. Hair loss
- C. Nausea
- D. Dry mouth
Correct Answer: D
Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.
What is the priority nursing action for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Administer corticosteroids
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.
A nurse is providing teaching to a client who is at 28 weeks of gestation and is scheduled for a glucose tolerance test. Which of the following instructions should the nurse include?
- A. You should avoid consuming any food or drink for 8 hours before the test.
- B. You should drink 8 oz of water 1 hour before the test.
- C. You should take an antacid before the test.
- D. You should drink a glass of milk 1 hour before the test.
Correct Answer: A
Rationale: Clients should avoid consuming any food or drink for 8 hours before the glucose tolerance test to ensure accurate results. Choice A is the correct instruction for the client preparing for a glucose tolerance test. Drinking water, taking an antacid, or consuming milk before the test can interfere with the accuracy of the results. Water or any other substance might affect the concentration of glucose in the blood, leading to inaccurate test results. Antacids and milk can also interfere with the test outcome. Therefore, the client should follow the instruction to fast for 8 hours before the test.
What is the initial intervention for a patient with chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Provide pain relief
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.
A healthcare provider is teaching a client who has a new prescription for levothyroxine. Which of the following instructions should the healthcare provider include?
- A. Take this medication with meals.
- B. Take this medication at the same time every day.
- C. Report any chest pain to your healthcare provider immediately.
- D. Take an antacid if indigestion occurs.
Correct Answer: B
Rationale: The correct instruction for a client prescribed levothyroxine is to take the medication at the same time every day. This consistency is important for maintaining stable thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach to ensure proper absorption. Choice C is important but not directly related to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.