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What is the priority nursing action for a patient with respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer bronchodilators
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.
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A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of canned vegetables.
- B. I will limit my daily sodium intake to 2 grams.
- C. I will increase my intake of whole grains.
- D. I will reduce my intake of processed meats.
Correct Answer: D
Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.
How should a healthcare professional monitor a patient for infection post-surgery?
- A. Monitor the surgical site
- B. Monitor for fever
- C. Check blood pressure
- D. Check for redness
Correct Answer: A
Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.
What is the best intervention for a patient experiencing respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Administer IV fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is crucial in ensuring that the patient receives an adequate supply of oxygen to meet the body's demands. Administering bronchodilators (Choice B) may be beneficial in specific respiratory conditions like asthma or COPD but may not be the primary intervention in all cases of respiratory distress. Administering IV fluids (Choice C) may be necessary in cases of dehydration or shock but would not directly address respiratory distress. Providing chest physiotherapy (Choice D) can help mobilize secretions in conditions like cystic fibrosis but is not the first-line intervention for respiratory distress.
A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct Answer: B
Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.
A client has a prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication with food.
- B. Avoid taking antacids at the same time as this medication.
- C. Take this medication if your heart rate is above 100/min.
- D. Notify your provider if you experience nausea or visual changes.
Correct Answer: D
Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.