Nokea
Which of the following is the best intervention for managing dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor fluid and electrolyte levels
- C. Encourage the client to drink more fluids
- D. Administer intravenous fluids
Correct Answer: B
Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.
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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.
How should a healthcare professional care for a patient with a colostomy?
- A. Empty the colostomy bag regularly
- B. Provide a high-fiber diet
- C. Monitor for signs of infection
- D. Change the colostomy bag every 3 days
Correct Answer: A
Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.
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 nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct Answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?
- A. Apply oxygen at 10 L/min via face mask
- B. Position the client on their side
- C. Call for a Cesarean delivery
- D. Administer oxytocin
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.