Nokea
What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?
- A. Notify the healthcare provider
- B. Reorient the client
- C. Increase circulation
- D. Assess the level of pain
Correct Answer: B
Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.
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What is the best intervention for a client who is vomiting after surgery?
- A. Administer antiemetics
- B. Place the client in a supine position
- C. Encourage deep breathing
- D. Administer morphine
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.
What is the most appropriate intervention for a client with shortness of breath and chest tightness?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Apply a cold compress
- D. Administer IV antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.
A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?
- A. I should inspect my feet daily for cuts or blisters.
- B. I can wear tight shoes to avoid blisters.
- C. I should avoid walking barefoot to prevent injuries.
- D. I should keep my blood glucose levels within the target range.
Correct Answer: B
Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.
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.
When the nurse is assessing a patient for pain, what is the most appropriate action to take?
- A. Ask the patient to rate pain intensity
- B. Ask about any allergies
- C. Ask the patient to describe the pain
- D. Measure pain intensity using a scale
Correct Answer: A
Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.