Nokea
What is the best way to assess a patient's respiratory function after surgery?
- A. Check oxygen saturation
- B. Auscultate lung sounds
- C. Check for abnormal breath sounds
- D. Check skin color
Correct Answer: A
Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.
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What is the initial step in managing a suspected pulmonary embolism in a patient?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer anticoagulants
- D. Administer IV fluids
Correct Answer: A
Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.
Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.
How should a healthcare professional manage a patient with fluid overload in heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor intake and output
- D. Administer diuretics
Correct Answer: A
Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.
When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with the removal
- D. Increase fluid intake before the procedure
Correct Answer: A
Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.
A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?
- A. Tell me about your siblings
- B. Tell me what kind of music you like
- C. Tell me how often you drink alcohol
- D. Tell me about your school schedule
Correct Answer: C
Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.