Nokea
What is the priority intervention for a patient presenting with chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Reposition the patient
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.
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What is the initial intervention for a patient experiencing an allergic reaction?
- A. Administer antihistamines
- B. Administer corticosteroids
- C. Administer oxygen
- D. Administer IV fluids
Correct Answer: A
Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.
What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon
- B. Provide oral glucose
- C. Administer IV fluids
- D. Monitor blood sugar levels
Correct Answer: B
Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct Answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.
A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Apply a dry dressing.
- B. Cleanse the wound with normal saline.
- C. Perform debridement as needed.
- D. Apply a hydrocolloid dressing.
Correct Answer: D
Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum calcium
- B. Blood glucose
- C. Serum protein
- D. Serum albumin
Correct Answer: D
Rationale: The correct answer is D, Serum albumin. Serum albumin levels are a good indicator of the nutritional effectiveness of total parenteral nutrition (TPN). Monitoring serum albumin levels helps assess the client's overall protein status and nutritional adequacy. Choices A, B, and C are not direct indicators of the effectiveness of TPN therapy. Serum calcium levels may be affected by other factors, blood glucose monitoring is more relevant for clients with diabetes or those receiving insulin therapy, and serum protein is not as specific as serum albumin in evaluating TPN effectiveness.