Nokea
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
- A. Assess the client's neurologic status
- B. Start an intravenous line and administer thrombolytics
- C. Monitor the client's ECG
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
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What is the nurse's priority when caring for a client with respiratory distress?
- A. Administer oxygen
- B. Administer albuterol
- C. Place the client on their back
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.
While obtaining the history from the mother of a 2-year-old with pneumonia, the nurse asks the mother if she smoked or used drugs during her pregnancy. Her response is, "What does that have to do with pneumonia?" How would the nurse answer her question?
- A. "You don't need to answer if it makes you uncomfortable."
- B. "It's not really that important; we have to ask everyone these questions."
- C. "The use of tobacco during your pregnancy could be the cause of your daughter's pneumonia."
- D. "Knowing about your pregnancy will help us get a more complete picture of your daughter's health."
Correct Answer: D
Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions.
Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.
Which disease is least likely to be associated with increased potential for bleeding?
- A. metastatic liver cancer
- B. gram-negative septicemia
- C. pernicious anemia
- D. iron-deficiency anemia
Correct Answer: C
Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.
What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.
What is the most appropriate intervention for a client with a history of seizures?
- A. Administer antiepileptics
- B. Monitor vital signs
- C. Apply oxygen therapy
- D. Monitor ECG
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptics. This is the most appropriate intervention for a client with a history of seizures as antiepileptic medications help prevent or reduce the frequency of seizures. Monitoring vital signs (B) is important but does not directly address the underlying issue of seizures. Oxygen therapy (C) may be needed during a seizure but does not prevent future episodes. Monitoring ECG (D) may provide information on cardiac function but is not the primary intervention for seizures. Administering antiepileptics is essential for seizure management.