Nokea
What is the most important nursing intervention for a client with pneumonia?
- A. Administer antibiotics
- B. Administer fluids
- C. Monitor temperature
- D. Administer vaccines
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating pneumonia caused by bacteria. They help to kill the bacteria causing the infection and prevent its spread. Administering fluids (B) is important for hydration but not the most crucial intervention. Monitoring temperature (C) is important but does not treat the root cause. Administering vaccines (D) may prevent certain types of pneumonia but is not the immediate intervention for an existing infection. Administering antibiotics promptly is vital to effectively treat pneumonia and prevent complications.
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What is the most important intervention when caring for a client with suspected pneumonia?
- A. Administer IV antibiotics
- B. Administer pain medications
- C. Administer antiemetics
- D. Administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer IV antibiotics. Administering IV antibiotics is crucial in treating pneumonia as it helps combat the underlying bacterial infection causing pneumonia. Prompt antibiotic therapy can prevent complications and improve patient outcomes. Administering pain medications (B) may help manage symptoms but does not address the root cause. Administering antiemetics (C) may help with nausea and vomiting but does not directly treat pneumonia. Option D is similar to the correct answer but lacks the specificity of IV antibiotics, which are often preferred for severe cases.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
- A. Perform a neurological assessment
- B. Initiate a stroke protocol
- C. Position the client on their side
- D. Start a CT scan
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
What is the best nursing action for a client with a wound infection?
- A. Administer antibiotics
- B. Apply sterile dressing
- C. Monitor blood pressure
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing.
Explanation of why other choices are incorrect:
B: Applying a sterile dressing is important for wound care but does not address the underlying infection.
C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection.
D: Placing the client in a sitting position is not relevant to treating a wound infection.
Which food should a client with hypercholesterolemia decrease in their diet?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.