Nokea
What is the priority intervention for a patient with dehydration?
- A. Administer IV fluids
- B. Monitor intake and output
- C. Administer oral fluids
- D. Provide electrolyte replacement
Correct Answer: A
Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.
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A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
- A. Avoid eating small, frequent meals.
- B. Sleep with the head of your bed elevated.
- C. Lie down after eating.
- D. Avoid drinking fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.
A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?
- A. Stoma that is red and moist
- B. Purulent drainage from the stoma
- C. Stoma that is dry and purple
- D. Mild swelling around the stoma
Correct Answer: C
Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.
A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?
- A. Limit the client's sodium intake to 4 grams per day.
- B. Measure the client's abdominal girth daily.
- C. Monitor the client's urine specific gravity every 12 hours.
- D. Encourage the client to drink 3 liters of fluid per day.
Correct Answer: B
Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.
What is the most concerning electrolyte imbalance for a patient receiving digoxin?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: The correct answer is Hypokalemia. Hypokalemia is the most concerning electrolyte imbalance for a patient receiving digoxin because it can increase the risk of digoxin toxicity. Low potassium levels can potentiate the effects of digoxin on the heart, leading to serious cardiac arrhythmias. Hyperkalemia (Choice A) is not typically associated with digoxin use. Hyponatremia (Choice C) and Hypercalcemia (Choice D) are not directly related to digoxin therapy and do not pose the same risk of toxicity.
What is the priority nursing intervention for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Monitor oxygen saturation
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.