Nokea
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?
- A. Follow-up on lab values before the visit.
- B. Observe client findings for the effectiveness of antibiotics.
- C. Ask for a log of urinary output.
- D. As for the log of the oral intake.
Correct Answer: B
Rationale: Monitoring antibiotic effectiveness is crucial in managing pyelonephritis.
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A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
The World Health Organization (WHO) recommends the use of three-step analgesic ladder when deciding on pain management. In order of first choice to second choice to third choice, the following drug categories are used:
- A. NSAIDs,nonopioids and opioids
- B. Nonopioids opioid antagonists and opioids
- C. Nonopioids opioids and adjuvant agents
- D. NSAIDs opioids and adjuvant agent
Correct Answer: C
Rationale: The WHO analgesic ladder starts with nonopioid analgesics (e.g., acetaminophen), progresses to weak opioids if needed, and finally includes strong opioids along with adjuvant therapies for severe pain.
Which stage of wound healing lasts from 21 days to several months and even 1 to 2 years, allowing the strength of the wound to increase through synthesis of collagen by fibroblasts and lysis by collagenase enzymes?
- A. Inflammatory stage
- B. Proliferative phase
- C. Maturation phase
- D. Approximation phase
Correct Answer: C
Rationale: The correct answer is C because the maturation phase involves collagen remodeling and strengthening.
You have just received the morning report from the night shift nurses. List the order of priority for assessing and caring for these patients.
- A. A patient who developed tumor lysis syndrome around 5:00 am.
- B. A patient with frequent reports of break-through pain over the past 24 hours.
- C. A patient scheduled for exploratory laparotomy this morning.
- D. A patient with anticipatory nausea and vomiting for the past 24 hours.
Correct Answer: A
Rationale: Tumor lysis syndrome is a life-threatening condition requiring immediate intervention, making it the top priority.
Liz is an elderly woman brought in by concerned family members. After physical examination, she was diagnosed with dehydration. What assessment findings would you expect to see?
- A. Bradycardia,slowed respirations low body temperature and weight gain.
- B. Rales peripheral edema palpitations and diaphoresis.
- C. Tachypnea tachycardia hypotension poor skin turgor and decreased urinary output.
- D. Malaise lymphadenopathy fever shortness of breath and nausea.
Correct Answer: C
Rationale: The correct answer is Tachypnea, tachycardia, hypotension, poor skin turgor, and decreased urinary output (C). Dehydration leads to reduced blood volume, causing compensatory mechanisms like tachycardia and tachypnea. Poor skin turgor and decreased urinary output are classic signs of fluid loss.