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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. What is the first intervention for a patient in shock?
- A. Administer fluids
- B. Monitor blood pressure
- C. Provide oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.
3. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Pressured speech
- B. Increased appetite
- C. Lack of sleep
- D. Mood swings
Correct answer: C
Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.
4. How should a healthcare professional respond to a patient with diabetic ketoacidosis (DKA)?
- A. Administer insulin
- B. Administer IV fluids
- C. Monitor blood glucose
- D. All of the above
Correct answer: D
Rationale: When managing a patient with diabetic ketoacidosis (DKA), it is crucial to administer insulin to lower blood sugar levels, administer IV fluids to correct dehydration and electrolyte imbalances, and monitor blood glucose levels regularly to ensure they are within the target range. Therefore, all of the above options are essential components of the comprehensive treatment plan for DKA. Administering insulin alone may lower blood sugar levels but will not address the fluid and electrolyte imbalances seen in DKA. Similarly, administering IV fluids alone may help with dehydration but will not address the high blood sugar levels or the need for insulin. Monitoring blood glucose alone is not sufficient to treat DKA; it must be accompanied by appropriate interventions to address the underlying causes and complications of the condition.
5. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?
- A. Instruct the client to rest completely and avoid all self-care tasks
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to complete all self-care tasks
- D. Ask the client's family to assist with self-care tasks
Correct answer: B
Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.
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