Nokea
What is the most important intervention for a client with acute pancreatitis?
- A. Administer pain relief
- B. Administer fluids
- C. Administer IV fluids
- D. Administer nitroglycerin
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.
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Which of the following statements accurately describes the concept of culturally competent care?
- A. The health care provider is able to understand and speak the patient's mother tongue.
- B. The health care provider possesses a basic knowledge of the patient's cultural background.
- C. The health care provider has knowledge of the significance of social, economic, and cultural contexts.
- D. The health care provider applies knowledge, skills, attitudes, and personal attributes to maximize respect and care.
Correct Answer: D
Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care.
Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care.
Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care.
Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care.
Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
What is the most appropriate intervention for a client with a wound infection?
- A. Administer antibiotics
- B. Apply sterile dressing
- C. Cleanse and dress the wound
- D. Administer analgesics
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. This is the most appropriate intervention for a wound infection as antibiotics target the underlying bacterial infection causing the wound infection. Antibiotics help to eliminate the infection and prevent it from spreading further. Administering antibiotics is crucial in treating wound infections to promote healing and prevent complications.
Choice B (Apply sterile dressing) is incorrect as simply applying a sterile dressing does not address the underlying infection. Choice C (Cleanse and dress the wound) is also incorrect because while wound cleansing is important, it alone may not be sufficient to treat a wound infection. Choice D (Administer analgesics) is incorrect because analgesics only provide pain relief and do not address the infection itself.
A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?
- A. Ruddy blue
- B. Generalized pallor
- C. Ashen, grey, or dull
- D. Patchy areas of pallor
Correct Answer: C
Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion.
The other choices are incorrect because:
A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent.
B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock.
D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.
What is the most appropriate intervention for serosanguineous drainage after cholecystectomy?
- A. notify the physician of the drainage
- B. change the dressing
- C. reinforce the dressing
- D. apply an abdominal binder
Correct Answer: C
Rationale: Rationale:
C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.