Nokea
What is the initial intervention for a patient experiencing an allergic reaction?
- A. Administer antihistamines
- B. Administer corticosteroids
- C. Administer oxygen
- D. Administer IV fluids
Correct Answer: A
Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.
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A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
- A. Lipsmacking
- B. Agranulocytosis
- C. Clang association
- D. Alopecia
Correct Answer: A
Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.
A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?
- A. Heart rate of 90/min
- B. Blood pressure of 118/76 mm Hg
- C. Warmth and redness in the calf
- D. Pink-tinged urine
Correct Answer: C
Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.
A nurse is caring for a client who is 32 weeks pregnant and has cardiac disease. Which of the following positions should the nurse place the client in to promote optimal cardiac output?
- A. Semi-Fowler's
- B. Supine with head elevated
- C. Left lateral
- D. Right lateral
Correct Answer: C
Rationale: The correct answer is C: Left lateral. Placing the client in the left lateral position helps promote optimal cardiac output during pregnancy by avoiding pressure on the vena cava. This position improves venous return to the heart and subsequently cardiac output. Option A, Semi-Fowler's position, may not be the best choice for a client with cardiac disease as it does not alleviate pressure on the vena cava. Option B, supine with head elevated, can also compress the vena cava, reducing cardiac output. Option D, right lateral position, does not provide the same benefits as the left lateral position for cardiac output during pregnancy.
A nurse is providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat.
- C. I will sleep on my affected side.
- D. I will perform leg exercises every hour while awake.
Correct Answer: C
Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.
How should a healthcare provider monitor a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg swelling
- B. Encourage ambulation
- C. Check for redness
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct way for a healthcare provider to monitor a patient with suspected deep vein thrombosis (DVT) is to check for leg swelling. Leg swelling is a common symptom of DVT and monitoring for this sign is crucial for early detection and intervention. Encouraging ambulation may be beneficial for preventing DVT but is not the recommended method for monitoring an existing condition. Checking for redness may be useful in cases of superficial thrombophlebitis but is not specific to DVT. Monitoring oxygen saturation is more relevant for respiratory or cardiovascular conditions, not for DVT.