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What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?
- A. Inspect for visible pulsation
- B. Palpate for thrill
- C. Auscultate for bruit
- D. Percuss for dullness
Correct Answer: A
Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.
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What instructions should the nurse give to a client undergoing mammography?
- A. Be sure to use underarm deodorant
- B. Do not use underarm deodorant
- C. Do not eat or drink after midnight
- D. Have a friend drive you home
Correct Answer: B
Rationale: The correct answer is B: Do not use underarm deodorant. This is important because deodorant can interfere with the mammogram results, leading to false readings. It is crucial to have a clean and uncontaminated image for an accurate diagnosis. Choice A is incorrect as it can affect the quality of the mammogram. Choices C and D are irrelevant to the mammography procedure and not necessary instructions for the client.
A nurse is caring for a patient who has had a myocardial infarction. Which of the following medications should the nurse expect to be prescribed for this patient?
- A. Lisinopril.
- B. Acetaminophen.
- C. Furosemide.
- D. Hydrochlorothiazide.
Correct Answer: A
Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage.
Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function.
Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI.
Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI.
Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI.
Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.
Which medication should be administered first for a client with acute asthma exacerbation?
- A. Albuterol
- B. Epinephrine
- C. Levalbuterol
- D. IV corticosteroids
Correct Answer: A
Rationale: Step-by-step rationale for choosing Albuterol as the correct answer:
1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation.
2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action.
3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing.
4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects.
5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective.
6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
- A. Breathing, pain, sleep
- B. Breathing, sleep, pain
- C. Sleep, breathing, pain
- D. Sleep, pain, breathing
Correct Answer: A
Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first.
Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.
What is the priority nursing intervention for a client with a history of asthma experiencing wheezing?
- A. Administer oxygen
- B. Apply a bronchodilator
- C. Apply a cold compress
- D. Encourage deep breathing
Correct Answer: A
Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.