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What is the nurse's most appropriate response when a patient with hearing impairment is encountered?
- A. Assess the communication method preferred by the patient.
- B. Request the help of a sign language interpreter before meeting with the patient.
- C. Use loud and exaggerated facial movements when talking with the patient.
- D. Speak loudly and slowly because most older adults have hearing deficits.
Correct Answer: A
Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care.
Summary of other choices:
B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language.
C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication.
D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.
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What is the most appropriate intervention for a client with an obstructed airway?
- A. Administer oxygen
- B. Monitor respiratory rate
- C. Apply a cold compress
- D. Administer corticosteroids
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.
What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.
A nurse is caring for a patient with a history of chronic kidney disease. The nurse should monitor for which of the following complications related to decreased renal function?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Hypotension.
- D. Hypercalcemia.
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease.
Other choices are incorrect because:
B: Hypoglycemia is not typically associated with chronic kidney disease.
C: Hypotension may occur in kidney disease but is not directly related to decreased renal function.
D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for which of the following signs of fluid overload?
- A. Weight loss and increased appetite.
- B. Increased urine output and dehydration.
- C. Swelling in the legs and shortness of breath.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.
Which organ is responsible for the extensive metabolism of acetaminophen?
- A. Liver
- B. Kidneys
- C. Lungs
- D. Pancreas
Correct Answer: A
Rationale: The correct answer is A: Liver. The liver is responsible for the extensive metabolism of acetaminophen through various pathways, including glucuronidation, sulfation, and oxidation. It converts acetaminophen into less toxic metabolites for elimination. The kidneys (B) primarily filter blood and regulate fluid balance; the lungs (C) are involved in gas exchange; and the pancreas (D) produces digestive enzymes and insulin, not involved in acetaminophen metabolism. Therefore, the liver is the correct choice for this question.