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What is the most appropriate intervention for a client with a wound infection?
- A. Administer antibiotics
- B. Apply sterile dressing
- C. Cleanse and dress the wound
- D. Administer analgesics
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. This is the most appropriate intervention for a wound infection as antibiotics target the underlying bacterial infection causing the wound infection. Antibiotics help to eliminate the infection and prevent it from spreading further. Administering antibiotics is crucial in treating wound infections to promote healing and prevent complications.
Choice B (Apply sterile dressing) is incorrect as simply applying a sterile dressing does not address the underlying infection. Choice C (Cleanse and dress the wound) is also incorrect because while wound cleansing is important, it alone may not be sufficient to treat a wound infection. Choice D (Administer analgesics) is incorrect because analgesics only provide pain relief and do not address the infection itself.
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What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.
What is the most important intervention when caring for a client with suspected pneumonia?
- A. Administer IV antibiotics
- B. Administer pain medications
- C. Administer antiemetics
- D. Administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer IV antibiotics. Administering IV antibiotics is crucial in treating pneumonia as it helps combat the underlying bacterial infection causing pneumonia. Prompt antibiotic therapy can prevent complications and improve patient outcomes. Administering pain medications (B) may help manage symptoms but does not address the root cause. Administering antiemetics (C) may help with nausea and vomiting but does not directly treat pneumonia. Option D is similar to the correct answer but lacks the specificity of IV antibiotics, which are often preferred for severe cases.
The nurse is assessing a teenage girl newly admitted to the pediatric unit. What efficient framework provides additional modesty?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy.
A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach.
B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health.
C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.
A nurse is providing education to a patient with chronic kidney disease. Which of the following dietary recommendations should the nurse prioritize?
- A. Increase protein intake.
- B. Increase potassium intake.
- C. Limit phosphorus and potassium intake.
- D. Decrease fluid intake.
Correct Answer: C
Rationale: The correct answer is C: Limit phosphorus and potassium intake. Patients with chronic kidney disease often have difficulty excreting phosphorus and potassium, leading to potential complications. Limiting phosphorus and potassium intake can help prevent further kidney damage and maintain electrolyte balance. Prioritizing this dietary recommendation is crucial for managing the progression of the disease.
Incorrect choices:
A: Increasing protein intake can put additional strain on the kidneys and may lead to further deterioration of kidney function.
B: Increasing potassium intake can be dangerous for patients with chronic kidney disease as they may have difficulty regulating potassium levels.
D: Decreasing fluid intake may be necessary in some cases, but it is not the priority in terms of managing chronic kidney disease.
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
- A. Perform a neurological assessment
- B. Initiate a stroke protocol
- C. Position the client on their side
- D. Start a CT scan
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.