Nokea
What is the most important nursing action for a patient presenting with confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological assessment
Correct Answer: A
Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.
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A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place a sensor on the index finger
Correct Answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.
Which medication is used to manage hyperthyroidism?
- A. Levothyroxine
- B. Methimazole
- C. Propylthiouracil
- D. Prednisone
Correct Answer: B
Rationale: Methimazole is the correct answer. It is commonly used to manage hyperthyroidism by inhibiting the production of thyroid hormones. Levothyroxine (Choice A) is actually a medication used to treat hypothyroidism by supplementing thyroid hormones. Propylthiouracil (Choice C) is another anti-thyroid medication used in the management of hyperthyroidism. Prednisone (Choice D) is a corticosteroid and is not typically used in the treatment of hyperthyroidism.
What is the priority intervention for a patient with fluid overload?
- A. Administer diuretics
- B. Administer IV fluids
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Weight gain
- C. Hypertension
- D. Decreased deep tendon reflexes
Correct Answer: D
Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Bowel sounds present in all four quadrants
- B. Temperature of 37.5°C (99.5°F)
- C. Scant urine output
- D. Serosanguineous wound drainage
Correct Answer: D
Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.