Nokea
What is the most appropriate intervention for a client with severe nausea and vomiting?
- A. Administer antiemetics
- B. Administer fluids
- C. Administer analgesics
- D. Monitor electrolytes
Correct Answer: A
Rationale: The correct answer is A: Administer antiemetics. Antiemetics help alleviate nausea and vomiting by blocking neurotransmitters in the brain. This intervention directly targets the symptoms and provides relief for the client. Administering fluids (B) may help with hydration but does not address the root cause. Administering analgesics (C) is for pain relief, not for nausea and vomiting. Monitoring electrolytes (D) is important but does not directly treat the symptoms. Therefore, administering antiemetics is the most appropriate intervention for severe nausea and vomiting.
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What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.
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.
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.
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.
A 47-year-old woman who is a recent immigrant to Canada is being seen at the clinic today for her uncontrolled diabetes. The nurse knows that the patient lives with her husband and a large extended family. The nurse concludes that part of the patient's inability to maintain and comply with her diet and diabetic regime is the foods that this patient eats. This conclusion is an example of:
- A. cultural sensitivity.
- B. cultural safety.
- C. cultural perspective.
- D. culturalism.
Correct Answer: D
Rationale: The correct answer is D: culturalism. The nurse's conclusion that the patient's inability to maintain her diet and diabetic regime is due to the foods she eats reflects culturalism. Culturalism refers to the belief that a person's behaviors and beliefs are solely determined by their culture. In this case, the nurse is attributing the patient's struggles solely to her cultural background without considering other factors.
A: Cultural sensitivity is about being aware and respectful of different cultures, but it does not involve making assumptions based on culture alone.
B: Cultural safety is about creating a safe and respectful environment for individuals from different cultures, but it does not involve making assumptions about behavior solely based on culture.
C: Cultural perspective involves understanding different cultural viewpoints, but it does not involve making assumptions about behavior solely based on culture.
In summary, the nurse's conclusion is an example of culturalism as it oversimplifies the patient's situation by attributing her struggles solely to her cultural background.