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What should be the nurse's first action for a client who has sustained a spinal cord injury?
- A. Immobilize the spine
- B. Assess the client's airway
- C. Place the client in a supine position
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.
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What is the most important intervention for a client with a wound infection?
- A. Administer antibiotics
- B. Apply a cold compress
- C. Apply heat to the wound
- D. Administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
- A. objective.
- B. reflective.
- C. subjective.
- D. introspective.
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Which food helps lower cholesterol?
- A. Fiber-rich foods
- B. Reduce diabetic ketoacidosis
- C. Lower cholesterol
- D. Reduce the need for folate
Correct Answer: C
Rationale: The correct answer is C: Lower cholesterol. Foods that help lower cholesterol typically include sources of soluble fiber, plant sterols, and healthy fats like omega-3 fatty acids. These components can lower LDL (bad) cholesterol levels and reduce the risk of heart disease. Fiber-rich foods (choice A) are beneficial for lowering cholesterol due to their ability to bind to cholesterol and remove it from the body. Reduce diabetic ketoacidosis (choice B) is unrelated to lowering cholesterol and is a serious complication of diabetes. Reduce the need for folate (choice D) is not directly related to cholesterol levels. Thus, the correct choice is C as it directly addresses the question about lowering cholesterol.
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.
What is the most important assessment for a client who has been receiving chemotherapy for several weeks?
- A. Check for signs of infection
- B. Monitor the client's weight
- C. Monitor the client's nutrition
- D. Check for skin changes
Correct Answer: A
Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.