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What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
- A. Administer oxygen
- B. Administer antibiotics
- C. Monitor blood glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
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A nurse is caring for a patient with diabetes who is newly diagnosed with diabetic nephropathy. The nurse should prioritize which of the following assessments?
- A. Kidney function tests.
- B. Blood pressure measurement.
- C. Blood glucose levels.
- D. Urine output monitoring.
Correct Answer: A
Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.
What should be the nurse's first priority for a client with an open wound?
- A. Clean and dress the wound
- B. Administer pain relief
- C. Administer anticoagulants
- D. Monitor blood pressure
Correct Answer: B
Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.
A nurse is assessing a patient's breath sounds and notes that the patient has a wheeze. This is most likely indicative of:
- A. Pneumonia.
- B. Asthma.
- C. Pulmonary embolism.
- D. Pleural effusion.
Correct Answer: B
Rationale: The correct answer is B: Asthma. Wheezing is a high-pitched whistling sound heard during expiration caused by narrowed airways in conditions like asthma. Pneumonia (A) typically presents with crackles, not wheezes. Pulmonary embolism (C) may cause sudden chest pain and shortness of breath but not wheezing. Pleural effusion (D) results in decreased breath sounds, not wheezes.
What does a comprehensive assessment include?
- A. Complete health history and physical exam
- B. Specific focus on a body system
- C. Emergency triage
- D. Specific assessment of client complaints
Correct Answer: A
Rationale: The correct answer is A because a comprehensive assessment involves gathering a complete health history and conducting a thorough physical examination to evaluate the client's overall health status. This includes assessing past medical history, family history, current medications, lifestyle factors, and performing a head-to-toe physical examination. This holistic approach helps in identifying any potential health issues or risk factors.
Choice B is incorrect because a specific focus on a body system is not comprehensive and may miss other important aspects of the client's health.
Choice C is incorrect as emergency triage is a rapid assessment to determine the severity of a medical condition and prioritize treatment, not a comprehensive assessment.
Choice D is incorrect because a specific assessment of client complaints is focused only on the reported issues and may not provide a comprehensive overview of the client's health.
What is the first action the nurse should take when a client presents with signs of respiratory distress?
- A. Open the airway
- B. Administer oxygen
- C. Administer medication
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.