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1. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?
- A. Ask the client to discuss their feelings
- B. Explain the importance of the medications
- C. Document the refusal and withhold the medication
- D. Inform the client of the possible consequences of refusal
Correct answer: D
Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.
2. What is the first step in managing a client with delirium?
- A. Administer sedative medication to calm the client
- B. Identify any reversible causes of delirium
- C. Limit environmental stimulation to reduce anxiety
- D. Administer antipsychotic medication to control behavior
Correct answer: B
Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.
3. How should a healthcare professional manage a patient with fluid overload?
- A. Restrict fluids and administer diuretics
- B. Increase fluid intake and provide oral diuretics
- C. Administer antibiotics and monitor weight
- D. Monitor weight and provide a low-sodium diet
Correct answer: A
Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.
4. What are the nursing interventions for a patient experiencing hypoglycemia?
- A. Administer glucose or dextrose and monitor blood sugar levels
- B. Monitor vital signs and provide a high-carbohydrate snack
- C. Monitor for sweating and confusion
- D. Provide insulin and assess for hyperglycemia
Correct answer: A
Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.
5. A client with a new diagnosis of type 2 diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information?
- A. Family members
- B. Pharmacist
- C. Dietitian
- D. American Diabetes Association
Correct answer: D
Rationale: The correct answer is D: American Diabetes Association. The American Diabetes Association is a reputable source that provides credible information on managing diabetes. While family members can offer support, they may not have the specialized knowledge on oral antidiabetic agents. Pharmacists are knowledgeable about medications but may not provide comprehensive information on diabetes management. Dietitians can offer valuable advice on nutrition but may not cover specific details about oral antidiabetic agents. Therefore, referring the client to the American Diabetes Association ensures access to accurate and detailed information related to their condition.
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