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What is the best nursing action for a client with a wound infection?
- A. Administer antibiotics
- B. Apply sterile dressing
- C. Monitor blood pressure
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing.
Explanation of why other choices are incorrect:
B: Applying a sterile dressing is important for wound care but does not address the underlying infection.
C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection.
D: Placing the client in a sitting position is not relevant to treating a wound infection.
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What is the most important intervention for a client with acute myocardial infarction (MI)?
- A. Administer aspirin
- B. Administer oxygen
- C. Administer morphine
- D. Administer nitroglycerin
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.
Which factors increase the risk of sexually transmitted diseases (STDs)?
- A. alcohol use
- B. certain types of sexual practices
- C. oral contraception use
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D: all of the above. Alcohol use can impair judgment leading to risky sexual behaviors. Certain sexual practices like unprotected sex or having multiple partners increase STD risk. Oral contraception does not protect against STDs. Therefore, all factors (A, B, C) collectively increase the risk of STDs.
What is the most appropriate intervention for a client with a history of seizures?
- A. Administer antiepileptics
- B. Monitor vital signs
- C. Apply oxygen therapy
- D. Monitor ECG
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptics. This is the most appropriate intervention for a client with a history of seizures as antiepileptic medications help prevent or reduce the frequency of seizures. Monitoring vital signs (B) is important but does not directly address the underlying issue of seizures. Oxygen therapy (C) may be needed during a seizure but does not prevent future episodes. Monitoring ECG (D) may provide information on cardiac function but is not the primary intervention for seizures. Administering antiepileptics is essential for seizure management.
A nurse is caring for a patient with chronic heart failure. Which of the following interventions is the priority?
- A. Administering diuretics as prescribed.
- B. Encouraging the patient to rest.
- C. Monitoring vital signs and fluid status.
- D. Teaching the patient about dietary changes.
Correct Answer: C
Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.
A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?
- A. Ask the patient to explain what they are feeling and what might have caused the behavior.
- B. Remain silent and allow the patient to continue at their own pace.
- C. Ask the patient if they feel nervous or worried about the pregnancy.
- D. Focus on making the patient feel heard and understood.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported.
Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.