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What should be the nurse's first priority for a client with an open wound?
- A. Clean and dress the wound
- B. Administer pain relief
- C. Administer anticoagulants
- D. Monitor blood pressure
Correct Answer: B
Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.
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A nurse is caring for a patient with a history of stroke. The nurse should prioritize which of the following interventions?
- A. Encouraging mobility to prevent pressure ulcers.
- B. Monitoring for signs of deep vein thrombosis (DVT).
- C. Administering antihypertensive medication.
- D. Providing psychological support.
Correct Answer: B
Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility.
Step 2: Monitoring for DVT signs is crucial for early detection and prevention.
Step 3: Prompt intervention can prevent life-threatening complications.
Step 4: Encouraging mobility (Choice A) is important but not the priority.
Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority.
Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.
What is the most important intervention when caring for a client with suspected pneumonia?
- A. Administer IV antibiotics
- B. Administer pain medications
- C. Administer antiemetics
- D. Administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer IV antibiotics. Administering IV antibiotics is crucial in treating pneumonia as it helps combat the underlying bacterial infection causing pneumonia. Prompt antibiotic therapy can prevent complications and improve patient outcomes. Administering pain medications (B) may help manage symptoms but does not address the root cause. Administering antiemetics (C) may help with nausea and vomiting but does not directly treat pneumonia. Option D is similar to the correct answer but lacks the specificity of IV antibiotics, which are often preferred for severe cases.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following to prevent complications?
- A. Administering pain medication regularly.
- B. Encouraging deep breathing exercises.
- C. Monitoring for signs of infection.
- D. Encouraging early ambulation.
Correct Answer: D
Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Pulmonary edema.
- C. Anemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function.
Rationale:
A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure.
C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema.
D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.
What is the most important intervention for a client with acute pancreatitis?
- A. Administer pain relief
- B. Administer fluids
- C. Administer IV fluids
- D. Administer nitroglycerin
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.