Nokea
What is the most appropriate intervention for a client with shortness of breath and chest tightness?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Apply a cold compress
- D. Administer IV antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.
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Which of the following statements is a characteristic of the clinical practice guidelines for infants and children for a periodic health examination?
- A. They are used to diagnose an illness.
- B. They are helpful in identifying developmental delays in children.
- C. They recommend that every individual receive an annual physical examination.
- D. They list a frequency schedule for periodic health visits for a specific age group.
Correct Answer: D
Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.
A nurse is caring for a patient with a history of stroke. The nurse should prioritize which of the following interventions?
- A. Encouraging mobility to prevent pressure ulcers.
- B. Monitoring for signs of deep vein thrombosis (DVT).
- C. Administering antihypertensive medication.
- D. Providing psychological support.
Correct Answer: B
Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility.
Step 2: Monitoring for DVT signs is crucial for early detection and prevention.
Step 3: Prompt intervention can prevent life-threatening complications.
Step 4: Encouraging mobility (Choice A) is important but not the priority.
Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority.
Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.
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.
What is the best intervention for a client who is vomiting after surgery?
- A. Administer antiemetics
- B. Place the client in a supine position
- C. Encourage deep breathing
- D. Administer morphine
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.
A nurse is teaching a patient about managing diabetes. Which of the following actions would the nurse emphasize as most important in preventing complications from diabetes?
- A. Monitoring blood glucose levels regularly.
- B. Limiting physical activity to prevent injury.
- C. Maintaining a low-fat, high-protein diet.
- D. Taking insulin as prescribed regardless of blood sugar levels.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment.
2. It helps in preventing hypoglycemia or hyperglycemia complications.
3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels.
4. Empowers the patient to make informed decisions regarding their diabetes management.
Summary of why the other choices are incorrect:
B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity.
C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively.
D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.