Nokea
What is the priority nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Perform a neurological exam
Correct Answer: A
Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.
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A client receiving a blood transfusion develops a fever. What action should the nurse take?
- A. Stop the transfusion immediately.
- B. Administer an antihistamine as prescribed.
- C. Administer a diuretic as prescribed.
- D. Increase the transfusion rate.
Correct Answer: A
Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.
A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
- A. Leavened bread may be eaten during Passover.
- B. Shellfish is commonly consumed in the diet.
- C. Meat and dairy products are eaten separately.
- D. Fasting from meat occurs during Hanukkah.
Correct Answer: C
Rationale: The correct answer is C. Kosher dietary laws require the separation of meat and dairy products. Choice A is incorrect because leavened bread is not eaten during Passover in Jewish dietary practices. Choice B is incorrect as shellfish is not considered kosher and is not consumed in Jewish dietary practices. Choice D is incorrect as fasting from meat does not occur during Hanukkah.
A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking fluids during the test.
- B. I will need to drink a sugar solution before the test.
- C. This test will monitor how my baby is responding to contractions.
- D. This test will assess for fetal lung maturity.
Correct Answer: B
Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.
Which lab value is critical for monitoring warfarin therapy?
- A. Monitor INR
- B. Monitor platelet count
- C. Monitor sodium levels
- D. Monitor calcium levels
Correct Answer: A
Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.
While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?
- A. Administer oxygen via nasal cannula
- B. Reposition the client onto her left side
- C. Administer an amnioinfusion
- D. Provide reassurance to the client
Correct Answer: B
Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.