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What is the priority intervention for a patient with suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Administer bronchodilators
- D. Reposition the patient
Correct Answer: A
Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.
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How should a healthcare professional respond to a patient who is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Encourage deep breathing exercises
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.
A nurse is providing teaching to a client who has a new diagnosis of hypertension. Which of the following dietary recommendations should the nurse include?
- A. Limit sodium intake to 4 grams per day.
- B. Limit protein intake to 80 grams per day.
- C. Limit saturated fat intake to 7% of daily calories.
- D. Limit fluid intake to 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is to limit saturated fat intake to 7% of daily calories. This recommendation is crucial for clients with hypertension to lower cholesterol levels and promote heart health. Choice A, limiting sodium intake to 4 grams per day, is important for hypertension but not the best recommendation compared to limiting saturated fats. Choice B, limiting protein intake to 80 grams per day, is not a primary dietary concern for hypertension. Choice D, limiting fluid intake to 1,500 mL per day, is not a standard recommendation for hypertension management.
Which lab value is most critical to monitor in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor magnesium levels
Correct Answer: A
Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.
A healthcare professional is reviewing laboratory results for a client who has cirrhosis. Which of the following findings should the professional report to the provider?
- A. Albumin 3.5 g/dL
- B. Bilirubin 1.0 mg/dL
- C. INR 3.0
- D. Ammonia 80 mcg/dL
Correct Answer: C
Rationale: An INR of 3.0 is elevated, indicating impaired blood clotting function, which poses a significant risk of bleeding in clients with cirrhosis. This finding should be promptly reported to the provider for further evaluation and management.
Choice A (Albumin 3.5 g/dL) is within the normal range and indicates adequate liver synthetic function, so it does not require immediate reporting. Choice B (Bilirubin 1.0 mg/dL) is also within the normal range and typically seen in clients without significant liver dysfunction, so it does not need urgent attention. Choice D (Ammonia 80 mcg/dL) is elevated, but it is not the priority finding in cirrhosis; elevated ammonia levels are associated with hepatic encephalopathy rather than increased bleeding risk.
A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?
- A. Instruct the client to use an alcohol-free mouthwash.
- B. Apply heat packs to the radiation site.
- C. Provide a diet low in carbohydrates.
- D. Avoid exposure to direct sunlight during treatment.
Correct Answer: D
Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.