Nokea
What is the first intervention for a patient experiencing anaphylactic shock?
- A. Administer epinephrine
- B. Administer corticosteroids
- C. Administer antihistamines
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.
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Which electrolyte imbalance is most common in patients receiving furosemide?
- A. Hypokalemia
- B. Hypercalcemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A, Hypokalemia. Furosemide, a loop diuretic, commonly leads to potassium loss in the urine, causing hypokalemia. This electrolyte imbalance should be closely monitored in patients taking furosemide. Choices B, C, and D are incorrect because hypercalcemia, hyponatremia, and hyperkalemia are not typically associated with furosemide use.
A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?
- A. Productive cough with green sputum
- B. Temperature of 37.1°C (98.8°F)
- C. Crackles in the lung bases
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
What is the appropriate action for a patient experiencing a severe allergic reaction?
- A. Administer epinephrine
- B. Administer antihistamines
- C. Administer corticosteroids
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps reverse the symptoms rapidly by constricting blood vessels, increasing heart rate, and opening airways. Antihistamines (Choice B) may help with mild allergic reactions but are not effective for severe cases. Corticosteroids (Choice C) are used to reduce inflammation and are typically not the first-line treatment for acute severe allergic reactions. Administering oxygen (Choice D) may be necessary to support breathing in severe cases, but epinephrine is the primary treatment to reverse the allergic reaction symptoms.
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administration of acetaminophen
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.
A nurse is caring for a client who is postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Place a pillow between the client's legs.
- B. Place the client in a high Fowler's position.
- C. Maintain the client in a side-lying position.
- D. Keep the client's legs elevated.
Correct Answer: A
Rationale: Placing a pillow between the client's legs is the correct action to prevent dislocation of the prosthesis after hip arthroplasty. This positioning helps maintain proper alignment and stability of the hip joint, reducing the risk of dislocation. Placing the client in a high Fowler's position (choice B) is not recommended after hip arthroplasty as it may strain the hip joint. Maintaining the client in a side-lying position (choice C) or keeping the client's legs elevated (choice D) does not provide the same level of support and alignment as placing a pillow between the legs.