Nokea
What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?
- A. Fluid restrictions are not needed for all clients with chronic kidney disease.
- B. You may need to limit fluid intake to prevent fluid overload.
- C. Fluid restrictions are based on your lab results and daily weights.
- D. Restricting fluids is only necessary during dialysis.
Correct Answer: B
Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.
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How should a healthcare professional manage a patient with congestive heart failure?
- A. Administer diuretics and monitor fluid balance
- B. Provide a high-sodium diet and restrict fluids
- C. Administer oxygen and provide pain relief
- D. Provide bronchodilators and encourage mobility
Correct Answer: A
Rationale: Correct answer: The most appropriate management for a patient with congestive heart failure is to administer diuretics to help remove excess fluid and monitor fluid balance. Diuretics help reduce the workload on the heart and alleviate symptoms of fluid overload. Choice B is incorrect because patients with congestive heart failure are usually advised to limit sodium intake and carefully monitor fluid intake. Choice C is incorrect because although oxygen therapy may be necessary in certain cases, it is not the primary management for congestive heart failure. Pain relief is not a primary intervention for this condition. Choice D is incorrect because bronchodilators are not the first-line treatment for congestive heart failure. Encouraging mobility is important, but administering diuretics and monitoring fluid balance take precedence in managing this condition.
A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?
- A. Heart rate 80/min
- B. Heart rate 90/min
- C. Respiratory rate 28/min
- D. Heart rate 146/min
Correct Answer: D
Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.
What are the key interventions for managing pneumonia?
- A. Administer antibiotics and monitor oxygen levels
- B. Administer bronchodilators and encourage deep breathing
- C. Provide fluids and monitor for dehydration
- D. Administer oxygen and provide bed rest
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct Answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.
A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor daily fluid intake
- B. Monitor blood glucose levels
- C. Measure intake and output
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.