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Question 1 of 5
What precaution should the nurse take when administering intravenous electrolyte solution?
Correct Answer: C
Rationale: The correct answer is C. The nurse should prevent infiltration of calcium to avoid tissue necrosis and sloughing. Infiltration of calcium can lead to severe tissue damage due to its caustic nature. Therefore, the nurse should be vigilant in monitoring the IV site and ensuring proper placement to prevent this complication. Choice A is incorrect because infusing hypertonic solutions rapidly can lead to fluid overload and electrolyte imbalances. Choice B is incorrect because exceeding the recommended amount of potassium per liter of fluid can result in hyperkalemia, which can be dangerous. Choice D is incorrect because calcium does not diminish digitalis's action; in fact, calcium can potentiate the effects of digitalis.
Question 2 of 5
A nurse is teaching a patient about managing hypertension. Which of the following dietary changes should the nurse recommend?
Correct Answer: B
Rationale: Step 1: Increasing potassium intake helps lower blood pressure by counteracting the effects of sodium. Step 2: Potassium helps relax blood vessel walls, reducing blood pressure. Step 3: Adequate potassium intake also helps the body balance fluids and maintain normal blood pressure. Summary: A - Increasing sodium intake is counterproductive for hypertension. C - Limiting caffeine helps, but not as directly as increasing potassium. D - Fruits and vegetables are important for a heart-healthy diet and should not be reduced.
Question 3 of 5
A nurse is caring for a 75-year-old patient with diabetes. What is the most important nursing action when assessing this patient?
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.
Question 4 of 5
The nurse is interviewing a patient who has a hearing impairment. What technique would be most beneficial in communicating with this patient?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Assessing the communication method preferred by the patient is crucial as it allows the nurse to tailor the communication approach to the patient's needs. 2. By understanding the patient's preferred communication method, the nurse can ensure effective and respectful communication. 3. This approach promotes patient-centered care and fosters a positive therapeutic relationship. 4. Avoiding facial expressions and hand gestures (B) can hinder communication and may not align with the patient's preferences. 5. Requesting a sign language interpreter (C) may be necessary for some patients, but assessing the patient's preferred method should be the initial step. 6. Speaking loudly and with exaggerated facial movement (D) can be ineffective and may not be the patient's preferred method of communication.
Question 5 of 5
What is the priority nursing action for a client with a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps to reverse the symptoms quickly and prevent further complications. Administering corticosteroids (B) may be considered later for long-term management, but epinephrine is the immediate priority. Administering oxygen (C) may help with respiratory distress but does not address the underlying allergic reaction. Applying a cold compress (D) may provide temporary relief for local reactions but is not effective for a severe systemic allergic reaction.
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