Nokea
What is the first intervention when a client develops symptoms of shock?
- A. Administer oxygen
- B. Administer IV fluids
- C. Monitor respiratory rate
- D. Administer pain medication
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.
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What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?
- A. Inspect for visible pulsation
- B. Palpate for thrill
- C. Auscultate for bruit
- D. Percuss for dullness
Correct Answer: A
Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.
Which condition places a client at risk for elevated ammonia levels?
- A. Renal failure
- B. Cirrhosis
- C. Psoriasis
- D. Lupus
Correct Answer: D
Rationale: The correct answer is D: Lupus. Lupus can affect the kidneys, leading to renal impairment. Renal impairment can decrease the body's ability to excrete ammonia, resulting in elevated levels. Renal failure (choice A) can also lead to elevated ammonia levels, but lupus specifically contributes to renal issues. Cirrhosis (choice B) primarily affects the liver, not kidneys. Psoriasis (choice C) is a skin condition and does not directly impact ammonia levels.
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
- A. Check the patency of the fistula
- B. Monitor for bleeding
- C. Administer IV fluids
- D. Apply an airtight dressing
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids
Rationale:
1. Assess patient's fluid status and hydration level.
2. IV fluids help maintain adequate hydration during hemodialysis.
3. Prevents hypotension and ensures stable blood pressure during the procedure.
4. Improves overall hemodialysis efficiency and patient safety.
Summary:
A: Checking patency is important, but not the primary intervention for hemodialysis.
B: Monitoring for bleeding is crucial but not specific to AVF assessment.
D: Applying an airtight dressing is not necessary for AVF assessment.
A nurse is caring for a patient who has had a myocardial infarction. Which of the following medications should the nurse expect to be prescribed for this patient?
- A. Lisinopril.
- B. Acetaminophen.
- C. Furosemide.
- D. Hydrochlorothiazide.
Correct Answer: A
Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage.
Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function.
Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI.
Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI.
Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI.
Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.
In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?
- A. This is necessary to determine the patient's reliability.
- B. Alcohol can interact with medications and can make some diseases worse.
- C. The nurse is required to teach the patient about the dangers of alcohol use.
- D. It is not really necessary to ask for this information unless there is an obvious drinking problem.
Correct Answer: B
Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.