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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. What should a healthcare professional assess in a patient presenting with symptoms of a stroke?
- A. Assess facial drooping
- B. Monitor speech difficulties
- C. Evaluate arm weakness
- D. Check for time of onset of symptoms
Correct answer: A
Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.
3. What are the nursing interventions for a patient with neutropenia?
- A. Monitor for signs of infection and administer antibiotics
- B. Isolate the patient and provide a low-microbial diet
- C. Monitor vital signs and avoid unnecessary invasive procedures
- D. Encourage the patient to engage in social activities
Correct answer: A
Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.
4. How should a healthcare provider assess a patient with sepsis?
- A. Monitor vital signs and administer fluids
- B. Monitor for fever and administer antibiotics
- C. Check for tachycardia and elevated white blood cell count
- D. Administer fluids and provide nutritional support
Correct answer: A
Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.
5. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?
- A. White flour tortillas.
- B. Potato pancakes.
- C. Wheat crackers.
- D. Canned barley soup.
Correct answer: B
Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.
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