Nokea
What is the most effective action for a client with suspected sepsis?
- A. Administer antibiotics
- B. Administer fluids
- C. Administer fluids
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.
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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.
What is the priority action for a client who presents with symptoms of stroke?
- A. Perform a CT scan
- B. Monitor blood pressure
- C. Administer aspirin
- D. Administer thrombolytics
Correct Answer: A
Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.
Which of the following statements is true regarding respect for differences?
- A. All patients will behave in the same way when asked questions by a health care provider.
- B. Conveying respect for differences will build trust and welcome patients to share their understandings.
- C. Having cultural expectations is the key to understanding individual differences.
- D. Expressing one's culture is largely dependent on the amount of his or her exposure to Canadian values.
Correct Answer: B
Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.
In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?
- A. This is necessary to determine the patient's reliability.
- B. Alcohol can interact with medications and can make some diseases worse.
- C. The nurse is required to teach the patient about the dangers of alcohol use.
- D. It is not really necessary to ask for this information unless there is an obvious drinking problem.
Correct Answer: B
Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.
Which condition places a client at risk for elevated ammonia levels?
- A. Renal failure
- B. Cirrhosis
- C. Psoriasis
- D. Lupus
Correct Answer: D
Rationale: The correct answer is D: Lupus. Lupus can affect the kidneys, leading to renal impairment. Renal impairment can decrease the body's ability to excrete ammonia, resulting in elevated levels. Renal failure (choice A) can also lead to elevated ammonia levels, but lupus specifically contributes to renal issues. Cirrhosis (choice B) primarily affects the liver, not kidneys. Psoriasis (choice C) is a skin condition and does not directly impact ammonia levels.