What is the most appropriate action when a patient is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.
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Which electrolyte imbalance is commonly seen in patients taking furosemide?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is commonly seen in patients taking furosemide and requires close monitoring. Choices B, C, and D are incorrect because furosemide does not typically cause hyponatremia, hyperkalemia, or hypercalcemia as frequently as it causes hypokalemia.
What is the first intervention for a patient experiencing anaphylactic shock?
- A. Administer epinephrine
- B. Administer oxygen
- C. Administer corticosteroids
- D. Administer antihistamines
Correct Answer: A
Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.
A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to check my blood glucose level once a week.
- B. I will limit my carbohydrate intake to 50 grams per day.
- C. I should avoid eating foods high in protein.
- D. I should eat a snack if my blood glucose level is below 200 mg/dL.
Correct Answer: D
Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.
A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.
Which lab value should be monitored in a patient on digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor digoxin levels
- D. Monitor sodium levels
Correct Answer: C
Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.