Nokea
What is the priority nursing intervention for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Administer corticosteroids
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators as the priority nursing intervention for a patient with an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing acute asthma symptoms. Administering corticosteroids (Choice B) is also important in the treatment plan, but it is not the priority intervention during an acute attack. Providing supplemental oxygen (Choice C) may be necessary but is not the priority initial intervention. Starting IV fluids (Choice D) is not typically indicated as a priority intervention for an acute asthma attack.
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A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?
- A. Cleanse the wound with povidone-iodine.
- B. Apply a hydrocolloid dressing.
- C. Perform debridement as needed.
- D. Keep the wound open to air.
Correct Answer: B
Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.
What should be monitored when administering opioids to a patient?
- A. Monitor blood pressure
- B. Monitor respiratory rate
- C. Monitor heart rate
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?
- A. I will take warfarin every other day.
- B. I will eat more leafy green vegetables while taking warfarin.
- C. I will use a soft toothbrush while taking warfarin.
- D. I will have my INR checked regularly while taking warfarin.
Correct Answer: B
Rationale: The correct answer is B. Eating more leafy green vegetables can increase vitamin K intake, which may reduce the effectiveness of warfarin. This can lead to fluctuations in the International Normalized Ratio (INR) levels, affecting the medication's efficacy. Choices A, C, and D are correct statements. Taking warfarin every other day, using a soft toothbrush to prevent gum bleeding, and having regular INR checks are all appropriate and important actions when taking warfarin.
How should signs of dehydration in an elderly patient be assessed?
- A. Monitor skin turgor
- B. Check for dry mucous membranes
- C. Monitor for sunken eyes
- D. Check capillary refill
Correct Answer: A
Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.
A client with a new diagnosis of hypertension is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will limit my saturated fat intake to 7% of daily calories.
- D. I will take my medication only when I have symptoms.
Correct Answer: C
Rationale: The correct answer is C because limiting saturated fat intake to 7% of daily calories is a crucial component of the dietary management for hypertension. This dietary modification helps reduce the risk of cardiovascular complications. Choices A, B, and D are incorrect. Choice A is incorrect because medication adherence should not be based on symptoms like dizziness. Choice B is inadequate as blood pressure monitoring should be more frequent, preferably daily, for effective management of hypertension. Choice D is incorrect because medication for hypertension should be taken consistently as prescribed, not just when symptoms occur.