Nokea
What is the most important nursing intervention for a client with severe dehydration?
- A. Administer IV fluids
- B. Monitor vital signs
- C. Provide oral rehydration
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.
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What is the most important action when caring for a client with respiratory distress?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Administer bronchodilators
- D. Administer analgesics
Correct Answer: A
Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.
A patient with heart failure tells the nurse, "I can't breathe very well at night." The nurse should ask:
- A. "Is the breathing difficulty worse when you're lying down?"
- B. "What has been the duration of your breathing problems?"
- C. "Do you feel short of breath during the day as well?"
- D. "Have you had any previous episodes of difficulty breathing?"
Correct Answer: A
Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.
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.
A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?
- A. Administering pain medication
- B. Performing a head-to-toe assessment
- C. Establishing an intravenous line
- D. Administering oxygen
Correct Answer: D
Rationale: Correct Answer: D - Administering oxygen
Rationale:
1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload.
2. Administering oxygen helps alleviate ischemia and prevents further damage.
3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being.
Summary of other choices:
A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction.
B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation.
C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.