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1. What are the key signs of hyperglycemia?
- A. Increased thirst and frequent urination
- B. Decreased appetite and low blood pressure
- C. Weight loss and nausea
- D. Increased sweating and confusion
Correct answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.
2. What are the key factors in assessing a patient's fall risk?
- A. Assess the patient's age and mobility
- B. Evaluate the patient's medication list for sedatives
- C. Assess the patient's vision and hearing
- D. Check for recent falls and cognitive impairment
Correct answer: A
Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.
3. What are the nursing interventions for a patient with COPD?
- A. Administer oxygen and provide breathing exercises
- B. Suction airway secretions and encourage coughing
- C. Administer bronchodilators and monitor oxygen saturation
- D. Restrict fluids and encourage mobility
Correct answer: A
Rationale: The correct answer is A: Administer oxygen and provide breathing exercises. These interventions are essential in managing COPD as they help improve lung function and oxygenation. Choice B is incorrect as suctioning airway secretions and encouraging coughing are not typically indicated for COPD patients. Choice C is incorrect as while administering bronchodilators is common in COPD treatment, monitoring oxygen saturation alone is not a comprehensive intervention. Choice D is incorrect as restricting fluids is not a standard intervention for COPD, and encouraging mobility, although beneficial, is not as directly related to managing COPD symptoms as administering oxygen and providing breathing exercises.
4. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?
- A. Administer oxytocin
- B. Perform fundal massage
- C. Administer IV fluids
- D. Call the provider
Correct answer: B
Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.
5. What is the role of a nurse in managing a patient with acute kidney injury (AKI)?
- A. Monitor urine output and electrolyte levels
- B. Administer diuretics and restrict potassium
- C. Provide dietary education and monitor fluid intake
- D. Administer antibiotics and check for dehydration
Correct answer: A
Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.
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