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1. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?
- A. Administer glucagon IM
- B. Give the client 4 oz of fruit juice
- C. Provide the client with peanut butter
- D. Give the client 1 L of water
Correct answer: B
Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.
2. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?
- A. Increase sodium intake to manage blood pressure
- B. Reduce caffeine and alcohol consumption
- C. Encourage the client to increase protein intake
- D. Increase intake of fruits and vegetables
Correct answer: B
Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.
3. Which intervention should be included for a client with heart failure?
- A. Encourage increased fluid intake
- B. Weigh the client daily to monitor fluid balance
- C. Restrict fluid intake during meals
- D. Limit daily activity to prevent fatigue
Correct answer: B
Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.
4. How should a healthcare provider assess and manage a patient with hyperthyroidism?
- A. Administer beta-blockers and monitor for signs of thyroid storm
- B. Encourage a high-protein, low-iodine diet
- C. Monitor for signs of bradycardia
- D. Provide iodine supplements and check for arrhythmias
Correct answer: A
Rationale: Administering beta-blockers is the initial management for hyperthyroidism to control symptoms such as tachycardia and tremors. Monitoring for signs of thyroid storm is crucial as it is a life-threatening complication of hyperthyroidism. Encouraging a high-protein, low-iodine diet (choice B) is not the primary intervention for managing hyperthyroidism. Monitoring for signs of bradycardia (choice C) is not typically seen in hyperthyroidism, as it often presents with tachycardia. Providing iodine supplements and checking for arrhythmias (choice D) are contraindicated in hyperthyroidism as they can worsen the condition.
5. What is the most effective way to prevent the spread of infection in a healthcare setting?
- A. Hand hygiene
- B. Wearing personal protective equipment
- C. Sterilizing equipment
- D. Isolating infected patients
Correct answer: A
Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.
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