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Question 1 of 5
A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:
Correct Answer: C
Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.
Question 2 of 5
A nurse is caring for a patient with a history of heart failure. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.
Question 3 of 5
What is the primary concern for a client with dehydration and hypotension?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.
Question 4 of 5
In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which of the following responses by the nurse is most appropriate?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and encourages the woman to share her coping mechanisms. This response acknowledges the woman's experience and allows her to express her feelings. It also opens up a dialogue for the nurse to assess her current coping strategies. Choice A is too general and does not prompt further discussion. Choice B is judgmental and dismissive of the woman's experiences. Choice D disregards the woman's emotional state and fails to address her current needs. Overall, Choice C is the most appropriate as it shows empathy, encourages open communication, and allows for further exploration of the woman's coping methods.
Question 5 of 5
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.
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