Nokea
Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?
- A. Use restraints to prevent the client from leaving the bed
- B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
- C. Encourage frequent ambulation with assistance
- D. Raise all four side rails to prevent falls
Correct Answer: B
Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.
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What are the early signs of hypoglycemia in a diabetic patient?
- A. Sweating and trembling
- B. Confusion and irritability
- C. Dizziness and increased heart rate
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.
How should a healthcare provider manage a patient with pneumonia?
- A. Administer antibiotics and provide oxygen therapy
- B. Provide bronchodilators and encourage deep breathing
- C. Administer fluids and encourage bed rest
- D. Monitor for chest pain and provide pain relief
Correct Answer: A
Rationale: Correct answer: Administering antibiotics and providing oxygen therapy are essential in managing pneumonia. Antibiotics help treat the infection caused by bacteria, while oxygen therapy improves lung function. Choice B is incorrect because bronchodilators may not be the primary treatment for pneumonia. Choice C is not the priority in pneumonia management, although fluids and rest are important for recovery. Choice D is also not a primary intervention in pneumonia management.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
- C. A client who has epidural analgesia and weakness in the lower extremities.
- D. A client who has a hip fracture and a new onset of tachypnea.
Correct Answer: D
Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.
A client who is postpartum is being taught about breast care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wear tight-fitting bras to reduce discomfort
- B. I will nurse my baby frequently to prevent engorgement
- C. I will pump my breasts every 4 hours
- D. I will avoid nursing for at least 48 hours
Correct Answer: B
Rationale: The correct answer is B. Nursing the baby frequently helps prevent engorgement and discomfort in breastfeeding mothers. Choice A is incorrect because tight-fitting bras can lead to clogged milk ducts and worsen discomfort. Choice C may lead to oversupply issues and is not necessary unless there is a specific indication. Choice D is incorrect as avoiding nursing for extended periods can lead to engorgement and decreased milk supply.
What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct Answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.