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What is the best intervention for a patient with respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Administer IV fluids
- D. Administer corticosteroids
Correct Answer: A
Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.
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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?
- A. Provide a low-sodium diet.
- B. Administer lorazepam as prescribed.
- C. Keep the client in a supine position.
- D. Place the client in restraints as prescribed.
Correct Answer: B
Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Bowel sounds present in all four quadrants
- B. Temperature of 37.5°C (99.5°F)
- C. Scant urine output
- D. Serosanguineous wound drainage
Correct Answer: D
Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.
A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?
- A. Limit the client's sodium intake to 4 grams per day.
- B. Measure the client's abdominal girth daily.
- C. Monitor the client's urine specific gravity every 12 hours.
- D. Encourage the client to drink 3 liters of fluid per day.
Correct Answer: B
Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.
A client is 2 days postoperative following a hip replacement surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Redness and warmth in the calf
- C. Urine output of 30 mL/hr
- D. Heart rate of 96/min
Correct Answer: B
Rationale: Redness and warmth in the calf can indicate a deep vein thrombosis (DVT), which is a serious complication following hip replacement surgery. It is crucial to report this finding promptly for further evaluation and intervention. The other options, heart rates of 88/min and 96/min, are within normal limits for an adult and may not require immediate reporting. A urine output of 30 mL/hr is concerning for decreased kidney perfusion, but the priority in this case is the potential DVT due to its severe implications.
A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?
- A. Stoma that is red and moist
- B. Purulent drainage from the stoma
- C. Stoma that is dry and purple
- D. Mild swelling around the stoma
Correct Answer: C
Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.