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What is the most important nursing action when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.
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A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?
- A. Crackles in the lung bases
- B. Oxygen saturation of 95%
- C. Heart rate of 88/min
- D. Frequent productive cough
Correct Answer: A
Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.
What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?
- A. Respect the patient's decision and notify the provider
- B. Attempt to persuade the patient to accept the transfusion
- C. Document the refusal and notify the healthcare provider
- D. Provide education on the benefits of blood transfusion
Correct Answer: A
Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.
How should a healthcare provider care for a patient with a tracheostomy?
- A. Clean the tracheostomy site daily
- B. Change the tracheostomy ties daily
- C. Suction the tracheostomy regularly
- D. Provide humidified oxygen
Correct Answer: C
Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.
A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day
- B. Avoid massaging the affected extremity to relieve pain
- C. Avoid applying cold packs to the client's affected extremity
- D. Elevate the client's affected extremity when in bed
Correct Answer: D
Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.
What is the best method to assess for fluid overload in patients with heart failure?
- A. Monitor daily weight
- B. Check for jugular vein distention
- C. Check for pitting edema
- D. Check for fluid retention
Correct Answer: A
Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.