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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. How should a healthcare professional care for a patient with a colostomy?
- A. Empty the colostomy bag regularly
- B. Provide a high-fiber diet
- C. Monitor for signs of infection
- D. Change the colostomy bag every 3 days
Correct answer: A
Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.
3. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
- A. Tachycardia
- B. Hypotension
- C. Increased urine output
- D. Diarrhea
Correct answer: C
Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice A) and hypotension (choice B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice D) can worsen dehydration and is not a positive response to IV fluid therapy.
4. Which of the following interventions is most appropriate for a client with a pressure ulcer who has a low albumin level?
- A. Increase protein intake to improve healing
- B. Consult with a dietitian to create a high-protein diet
- C. Provide nutritional supplements
- D. Increase IV fluid intake to improve hydration
Correct answer: B
Rationale: Consulting with a dietitian to create a high-protein diet is the most appropriate intervention for a client with a pressure ulcer and low albumin level. This intervention can help address the client's poor nutritional status, support wound healing, and specifically target the low albumin level. Increasing protein intake alone (Choice A) may not be sufficient without proper guidance. Providing nutritional supplements (Choice C) can be beneficial but consulting with a dietitian for a personalized plan is more effective in this case. Increasing IV fluid intake (Choice D) primarily targets hydration and may not directly address the underlying issue of low albumin and poor nutritional status.
5. What is the priority nursing action for a patient with an acute asthma attack?
- A. Administer a bronchodilator
- B. Monitor oxygen saturation
- C. Position the patient in a high Fowler's position
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.
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