Nokea
What is the most important intervention for a client experiencing an allergic reaction?
- A. Administer epinephrine
- B. Administer antihistamines
- C. Administer corticosteroids
- D. Administer beta-blockers
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.
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A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?
- A. I should inspect my feet daily for cuts or blisters.
- B. I can wear tight shoes to avoid blisters.
- C. I should avoid walking barefoot to prevent injuries.
- D. I should keep my blood glucose levels within the target range.
Correct Answer: B
Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
- A. Assess the client's neurologic status
- B. Start an intravenous line and administer thrombolytics
- C. Monitor the client's ECG
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
When interviewing a patient, it is important for the nurse to obtain some basic history. Which of the following statements should be explored more fully during an interview? The patient states that he:
- A. Sleeps like a baby.
- B. Has no health problems.
- C. Never did too good in school.
- D. Is currently not taking any medication.
Correct Answer: C
Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively.
A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality.
B: "Has no health problems" is important information but does not require immediate further exploration.
D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
- A. Elevate the affected leg
- B. Apply compression stockings
- C. Provide leg elevation
- D. Administer compression therapy
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain.
Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed.
Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly.
Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for which of the following signs of fluid overload?
- A. Weight loss and increased appetite.
- B. Increased urine output and dehydration.
- C. Swelling in the legs and shortness of breath.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.