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1. What are the complications of untreated fluid overload?
- A. Pulmonary edema and congestive heart failure
- B. Hypertension and electrolyte imbalance
- C. Liver failure and electrolyte imbalance
- D. Pulmonary embolism and dehydration
Correct answer: A
Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.
2. 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.
3. A nurse is providing discharge instructions to a client with oxygen therapy. What should the nurse emphasize?
- A. Avoid keeping oxygen tanks in an upright position
- B. Keep oxygen equipment at least 6 feet away from heat sources
- C. Allow family members to smoke in designated areas
- D. Restrict fluid intake while using oxygen therapy
Correct answer: B
Rationale: The correct answer is B: 'Keep oxygen equipment at least 6 feet away from heat sources.' It is crucial to keep oxygen equipment away from heat sources to prevent fire hazards. Option A is incorrect as oxygen tanks should be stored in an upright position. Option C is wrong because smoking near oxygen equipment poses a significant fire risk. Option D is also incorrect as fluid intake should not be restricted while using oxygen therapy; in fact, it is important to maintain adequate hydration.
4. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?
- A. Position the client on their left side
- B. Irrigate the NG tube with sterile water
- C. Replace the NG tube with a new one
- D. Increase the suction setting to relieve the blockage
Correct answer: B
Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.
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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