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1. What is the priority for a client with dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor electrolyte levels to prevent imbalances
- C. Administer oral rehydration solutions
- D. Administer intravenous fluids
Correct answer: B
Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.
2. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?
- A. 20 mL
- B. 15 mL
- C. 25 mL
- D. 10 mL
Correct answer: A
Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.
3. What is an important consideration in managing a patient with heart failure?
- A. Monitor daily weight
- B. Provide oxygen therapy
- C. Encourage low-sodium diet
- D. Monitor for signs of fluid overload
Correct answer: A
Rationale: The most important consideration in managing a patient with heart failure is to monitor daily weight. This allows healthcare providers to assess fluid retention, adjust medications based on weight changes, and detect early signs of worsening heart failure. While oxygen therapy may be necessary in acute situations, it is not a routine management strategy for stable heart failure patients. Encouraging a low-sodium diet is important to manage fluid retention, but daily weight monitoring is a more direct measure of fluid status. Monitoring for signs of fluid overload is essential, but monitoring daily weight is a proactive approach to detect fluid accumulation before overt symptoms appear.
4. A client diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?
- A. Limit intake of fresh fruits and uncooked vegetables
- B. Limit intake of red meat and shellfish
- C. Limit intake of dairy products
- D. Increase intake of leafy greens
Correct answer: B
Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.
5. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?
- A. Suction the airway every hour
- B. Keep the head of the bed at 30 degrees
- C. Change the ventilator tubing every day
- D. Administer a bronchodilator every 2 hours
Correct answer: B
Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.
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