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1. How should a healthcare professional assess a patient with chest pain?
- A. Assess the severity of pain and monitor ECG
- B. Administer nitroglycerin and provide oxygen
- C. Administer aspirin and provide pain relief
- D. Monitor for nausea and administer IV fluids
Correct answer: A
Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.
2. Which instruction should be emphasized for a client with diabetes being discharged?
- A. Check blood sugar once daily
- B. Take insulin before meals as prescribed
- C. Monitor glucose levels weekly
- D. Eat carbohydrate-rich meals to maintain glucose levels
Correct answer: B
Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.
3. What are the early signs and symptoms of sepsis?
- A. Increased heart rate and fever
- B. Low blood pressure and confusion
- C. Rapid breathing and sweating
- D. Abdominal pain and cyanosis
Correct answer: A
Rationale: The correct answer is A: Increased heart rate and fever. In sepsis, an increased heart rate and fever are common early signs of systemic infection. While choices B, C, and D can be present in later stages of sepsis, they are not typically the initial signs. Low blood pressure and confusion may occur in severe sepsis or septic shock. Rapid breathing and sweating can be seen as sepsis progresses. Abdominal pain and cyanosis may develop as the condition advances but are not usually the earliest signs.
4. A nurse is caring for a client who is constipated. What intervention is most appropriate?
- A. Administer a laxative to relieve discomfort
- B. Encourage the client to increase dietary fiber intake
- C. Encourage the client to rest until symptoms resolve
- D. Administer a stool softener as prescribed
Correct answer: B
Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.
5. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?
- A. Cancer of any kind
- B. Impaired hearing
- C. Prescription drug intoxication
- D. Heart failure
Correct answer: C
Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.
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