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1. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?
- A. Heart rate 60/min
- B. Increased urinary output
- C. Increased respiratory rate
- D. Hypothermia
Correct answer: C
Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.
2. What are the differences between viral and bacterial infections?
- A. Viral infections often cause fatigue and body aches
- B. Bacterial infections often cause high fever and localized pain
- C. Viral infections are treated with antibiotics
- D. Bacterial infections are usually self-limiting
Correct answer: A
Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.
3. A client with an acute myocardial infarction is concerned about extreme fatigue. What is the best strategy to promote independence in self-care?
- A. Instruct the client to limit all activity until fully rested
- B. Encourage the client to gradually resume self-care tasks with rest periods
- C. Assign assistive personnel to complete self-care tasks
- D. Ask the client's family to assist with self-care
Correct answer: B
Rationale: Encouraging the client to gradually resume self-care tasks with rest periods is the best strategy to promote independence in self-care for a client with acute myocardial infarction. This approach allows the client to regain independence while considering the need for rest to prevent overexertion. Instructing the client to limit all activity until fully rested (Choice A) may hinder independence by promoting inactivity. Assigning assistive personnel to complete self-care tasks (Choice C) does not promote the client's independence. Asking the client's family to assist with self-care (Choice D) may not foster the client's self-reliance and may not always be feasible.
4. What are the key considerations for managing a patient with chronic obstructive pulmonary disease (COPD)?
- A. Airway Management
- B. Oxygen Therapy
- C. Smoking Cessation
- D. Pulmonary Rehabilitation
Correct answer: A
Rationale: The key considerations for managing a patient with COPD include airway management, ensuring adequate oxygenation, promoting smoking cessation, and incorporating pulmonary rehabilitation. While airway management is crucial for maintaining patency and preventing exacerbations, oxygen therapy helps improve oxygen levels in the blood. Smoking cessation is essential to slow down disease progression and reduce exacerbation risk. Pulmonary rehabilitation plays a vital role in enhancing exercise tolerance and overall quality of life for COPD patients. Therefore, while all options are important in managing COPD, airway management is the most critical aspect.
5. How should a healthcare professional assess a patient with dehydration?
- A. Monitor skin turgor and check urine output
- B. Assess for jugular venous distention
- C. Auscultate lung sounds and monitor for fever
- D. Monitor for cyanosis and increased respiratory rate
Correct answer: A
Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.
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