Nokea
Which intervention is essential when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink water throughout the day
- B. Monitor the client's weight daily to assess fluid balance
- C. Limit fluid intake during meals
- D. Weigh the client once a week to assess fluid balance
Correct Answer: B
Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.
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What are the key nursing interventions for a patient undergoing dialysis?
- A. Monitor fluid balance and administer heparin
- B. Monitor blood pressure and prevent clot formation
- C. Administer medications and monitor blood chemistry
- D. Provide dietary education and encourage protein intake
Correct Answer: A
Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.
A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?
- A. Administer pain medication
- B. Reposition the client's leg
- C. Elevate the client's leg
- D. Check the client's neurovascular status
Correct Answer: D
Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.
A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?
- A. Ensure the chest tube is periodically clamped
- B. Check for air leaks in the tubing
- C. Keep the client in a prone position for chest drainage
- D. Administer diuretics to prevent fluid buildup
Correct Answer: B
Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.
A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?
- A. How severe is your pain on a scale of 1 to 10?
- B. Where is your pain located?
- C. What medication are you taking for the pain?
- D. When did the pain start?
Correct Answer: B
Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.
When caring for a client experiencing delirium, which of the following is essential?
- A. Controlling behavioral symptoms with low-dose psychotropics
- B. Identifying the underlying causative condition or illness
- C. Manipulating the environment to increase orientation
- D. Decreasing or discontinuing all previously prescribed medications
Correct Answer: B
Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.