Nokea
What is the first step in the care of a client with a severe allergic reaction?
- A. Administer epinephrine
- B. Administer corticosteroids
- C. Administer corticosteroids
- D. Apply a cold compress
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.
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A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
- A. Administering bronchodilators as prescribed.
- B. Encouraging the patient to avoid physical activity.
- C. Providing supplemental oxygen as needed.
- D. Monitoring for signs of acute kidney injury.
Correct Answer: A
Rationale: The correct answer is A: Administering bronchodilators as prescribed.
Rationale:
1. Bronchodilators help dilate the airways, improving airflow in COPD patients.
2. Priority is to address the underlying respiratory issue.
3. Bronchodilators are a standard treatment for managing COPD symptoms.
4. Improving airway patency is crucial in COPD exacerbations.
Summary:
- B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning.
- C: Providing supplemental oxygen is important but not the priority in this case.
- D: Monitoring for acute kidney injury is unrelated to COPD management.
A nurse is caring for a patient with a history of stroke. The nurse should monitor for which of the following complications?
- A. Pulmonary embolism.
- B. Deep vein thrombosis (DVT).
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Pulmonary embolism (A) is a potential complication of DVT but not the most direct concern. Hypertension (C) is a common condition but not directly linked to a history of stroke. Hyperglycemia (D) is more commonly associated with diabetes rather than stroke history. Monitoring for DVT in stroke patients is essential for early detection and intervention.
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
- A. Go on, I'm listening.
- B. Fits? Tell me what you mean by this.
- C. Yes, it can be upsetting when a child has a fit.
- D. Don't be upset when he has a fit; every 2-year-old has fits.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively.
Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.
A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
- A. J.M. is a 59-year-old male here for "ulcerative colitis."
- B. J.M. came into the clinic complaining of black stools in the past 24 hours.
- C. J.M., a 59-year-old male, states he has ulcerative colitis and wants to have it checked up.
- D. J.M. is a 59-year-old male here for having "black stools" in the past 24 hours.
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom.
Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
Which nursing intervention should be prioritized for a client with congestive heart failure (CHF)?
- A. Administer diuretics
- B. Limit fluid intake
- C. Promote activity
- D. Maintain fluid balance
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life.
Summary of Incorrect Choices:
A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity.
B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation.
D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.