Nokea
Which of the following is a priority intervention for a patient with suspected sepsis?
- A. Administering antibiotics.
- B. Administering IV fluids.
- C. Administering antipyretics.
- D. Monitoring blood cultures.
Correct Answer: D
Rationale: Monitoring blood cultures is a crucial intervention in suspected sepsis because it helps identify the causative organism, which is essential for guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important but should be guided by blood culture results. Administering IV fluids (Choice B) is also essential to support hemodynamic stability in sepsis. Administering antipyretics (Choice C) may help reduce fever but is not a priority compared to identifying the causative organism through blood cultures.
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The client with chronic renal failure is receiving peritoneal dialysis. Which of the following is the most important action for the nurse to take?
- A. Administer the prescribed antibiotics.
- B. Monitor for signs of infection.
- C. Encourage the client to increase fluid intake.
- D. Monitor the client's weight daily.
Correct Answer: B
Rationale: Monitoring for signs of infection is crucial in clients undergoing peritoneal dialysis. Peritonitis is a severe complication associated with peritoneal dialysis, making it essential to promptly identify any signs of infection, such as abdominal pain, cloudy dialysate, fever, and an elevated white blood cell count. Administering antibiotics without proper assessment can lead to antibiotic resistance and should not be the initial action. Encouraging increased fluid intake may not be appropriate without assessing the client's fluid status. Monitoring weight alone does not address the immediate risk of peritonitis in a client undergoing peritoneal dialysis.
After a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, assessing the client for a cerebrospinal fluid (CSF) leak is crucial due to the risk of this serious complication. A CSF leak can lead to infection and increased intracranial pressure, which must be promptly identified and managed to prevent further complications. Fluctuating blood glucose levels (Choice B) are not directly associated with a transsphenoidal hypophysectomy. Cushing's syndrome (Choice C) is a condition related to prolonged exposure to high levels of cortisol and is not a common immediate concern post-transsphenoidal hypophysectomy. Cardiac arrhythmias (Choice D) are not typically a direct complication of this surgical procedure, making it a less relevant concern compared to a CSF leak.
Which of the following is a characteristic symptom of hypothyroidism?
- A. Fatigue.
- B. Weight gain.
- C. Cold intolerance.
- D. Heat intolerance.
Correct Answer: C
Rationale: The correct answer is 'Cold intolerance.' Hypothyroidism is associated with a decreased metabolic rate, leading to a decreased ability to regulate body temperature and a feeling of being cold. Fatigue (Choice A) and weight gain (Choice B) are also common symptoms of hypothyroidism due to the overall slowing down of bodily functions. Heat intolerance (Choice D) is more commonly associated with hyperthyroidism, where the body's metabolism is overactive, leading to increased heat production.
A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return?
- A. Perform passive range of motion exercises
- B. Place the client in high Fowler's position
- C. Administer oxygen via nasal cannula
- D. Increase the client's activity level
Correct Answer: B
Rationale: In clients with heart failure, placing them in high Fowler's position is beneficial as it helps reduce venous return and improve ventilation. This position aids in decreasing the workload on the heart by promoting better lung expansion and oxygenation. Passive range of motion exercises (Choice A) are not directly related to improving ventilation or reducing venous return. Administering oxygen via nasal cannula (Choice C) may help with oxygenation but does not directly address reducing venous return. Increasing the client's activity level (Choice D) may worsen heart failure symptoms by increasing the workload on the heart.
The client with chronic renal failure is on a fluid restriction. Which of the following statements by the client indicates that the teaching has been effective?
- A. I will limit my fluid intake to prevent fluid overload.
- B. I can drink as much fluid as I want as long as I take my medication.
- C. I will skip dialysis sessions if I feel tired.
- D. I will limit my fluid intake to 1 liter per day.
Correct Answer: A
Rationale: Choice A is the correct answer because it demonstrates the client's understanding of the need to limit fluid intake to prevent fluid overload, which is crucial in managing chronic renal failure. Adequate fluid restriction is essential to prevent complications such as fluid overload and electrolyte imbalances. Choice B is incorrect as it promotes excessive fluid intake, which can worsen the client's condition by putting additional stress on the kidneys. Choice C is incorrect as skipping dialysis sessions can lead to a buildup of toxins in the body, worsening renal failure and potentially leading to life-threatening complications. Choice D is incorrect because limiting fluid intake to a specific volume may not be appropriate for all clients and can vary depending on individual needs, medical condition, and healthcare provider recommendations.