Nokea
What is the most important assessment for a client who has been receiving chemotherapy for several weeks?
- A. Check for signs of infection
- B. Monitor the client's weight
- C. Monitor the client's nutrition
- D. Check for skin changes
Correct Answer: A
Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.
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A nurse is teaching a patient with diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I will exercise regularly to help manage my condition.
- C. I will stop taking my insulin once my blood glucose is normal.
- D. I will eat a balanced diet and avoid sugary foods.
Correct Answer: C
Rationale: The correct answer is C. Stopping insulin once blood glucose is normal is incorrect as insulin is crucial for managing diabetes even when blood glucose levels are within the target range. Insulin helps regulate blood sugar levels consistently, and stopping it abruptly can lead to hyperglycemia. Choices A, B, and D are correct statements indicating good diabetes management practices. Monitoring blood glucose levels, exercising regularly, and following a balanced diet are essential for controlling blood sugar levels and overall health.
Which medication should be administered first for a client with acute asthma exacerbation?
- A. Albuterol
- B. Epinephrine
- C. Levalbuterol
- D. IV corticosteroids
Correct Answer: A
Rationale: Step-by-step rationale for choosing Albuterol as the correct answer:
1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation.
2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action.
3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing.
4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects.
5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective.
6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
- A. Check the patency of the fistula
- B. Monitor for bleeding
- C. Administer IV fluids
- D. Apply an airtight dressing
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids
Rationale:
1. Assess patient's fluid status and hydration level.
2. IV fluids help maintain adequate hydration during hemodialysis.
3. Prevents hypotension and ensures stable blood pressure during the procedure.
4. Improves overall hemodialysis efficiency and patient safety.
Summary:
A: Checking patency is important, but not the primary intervention for hemodialysis.
B: Monitoring for bleeding is crucial but not specific to AVF assessment.
D: Applying an airtight dressing is not necessary for AVF assessment.
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
- A. Administer nitroglycerin
- B. Monitor cardiac rhythm
- C. Assess the ECG
- D. Assist with positioning
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
- A. Breathing, pain, sleep
- B. Breathing, sleep, pain
- C. Sleep, breathing, pain
- D. Sleep, pain, breathing
Correct Answer: A
Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first.
Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.