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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. What is the first step in assessing a patient with suspected stroke?
- A. Check for facial droop
- B. Assess speech clarity
- C. Perform a neurological assessment
- D. Call for emergency assistance
Correct answer: D
Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.
3. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?
- A. Insert the suction catheter while the client is swallowing
- B. Apply intermittent suction when withdrawing the catheter
- C. Place the catheter in a clean, dry location for later use
- D. Hold the suction catheter with the non-dominant hand
Correct answer: B
Rationale: The correct technique when performing nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps reduce trauma to the mucosa by preventing prolonged suctioning. Choice A is incorrect because inserting the suction catheter while the client is swallowing may increase the risk of aspiration. Choice C is incorrect as placing the catheter in a clean, dry location for later use is not a safe practice as it can lead to contamination. Choice D is incorrect since it does not address the proper technique involved in nasotracheal suctioning.
4. A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?
- A. Give a bedtime snack
- B. Encourage a short nap in the afternoon
- C. Encourage exercise right before bed
- D. Establish a regular exercise routine 2 hours or more before bedtime
Correct answer: D
Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.
5. What is an essential nursing intervention for a client experiencing delirium?
- A. Control behavioral symptoms with low-dose psychotropics
- B. Identify the underlying causative condition
- C. Increase environmental stimulation
- D. Administer antipsychotic medication
Correct answer: B
Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.
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