What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon
- B. Provide oral glucose
- C. Administer IV fluids
- D. Monitor blood sugar levels
Correct Answer: B
Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.
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A client with rheumatoid arthritis is experiencing morning stiffness. Which of the following actions should the nurse take?
- A. Encourage the client to avoid physical activity in the morning.
- B. Encourage the client to take NSAIDs before bedtime.
- C. Apply cold packs to the affected joints in the morning.
- D. Perform passive range-of-motion exercises before getting out of bed.
Correct Answer: C
Rationale: The correct action the nurse should take is to apply cold packs to the affected joints in the morning. Rheumatoid arthritis is characterized by inflammation, and applying cold packs can help reduce inflammation and stiffness in the joints. Encouraging the client to avoid physical activity in the morning (Choice A) may worsen stiffness, as movement is beneficial for joint mobility. While NSAIDs (Choice B) can help with pain and inflammation, applying cold packs directly to the affected joints is more targeted and effective. Performing passive range-of-motion exercises (Choice D) can be helpful, but applying cold packs is the priority for reducing inflammation and stiffness.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
- A. Increased hoarseness
- B. Serum calcium level of 8.0 mg/dL
- C. Respiratory rate of 18/min
- D. Urinary output of 60 mL in 2 hours
Correct Answer: B
Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.
What should be monitored when administering opioids to a patient?
- A. Monitor blood pressure
- B. Monitor respiratory rate
- C. Monitor heart rate
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.
Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?
- A. Monitor platelet count
- B. Monitor PT/INR
- C. Monitor aPTT
- D. Monitor CBC
Correct Answer: C
Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.
What is the appropriate intervention for a patient with hypertension refusing medication?
- A. Educate the patient on the importance of medication
- B. Respect the patient's decision
- C. Inform the healthcare provider
- D. Explore alternative treatment options
Correct Answer: A
Rationale: The correct answer is A: Educate the patient on the importance of medication. Providing education to the patient is crucial in promoting understanding of the condition and the necessity of medication. By enhancing the patient's knowledge, healthcare providers can empower them to make informed decisions regarding their health. Choice B, respecting the patient's decision, may not be appropriate in this scenario as untreated hypertension can lead to serious complications. Choice C, informing the healthcare provider, is important but should be done after attempting to educate the patient. Choice D, exploring alternative treatment options, may be considered if the patient has concerns or side effects related to the medication, but initially, educating the patient about the importance of medication is key.