What should the nurse monitor first for a client with a recent stroke?

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Question 1 of 9

What should the nurse monitor first for a client with a recent stroke?

Correct Answer: C

Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.

Question 2 of 9

What is the primary intervention for a client with a history of falls who is at risk for injury?

Correct Answer: A

Rationale: The correct answer is A: Place the client in a safe environment. This is the primary intervention for a client with a history of falls to prevent further injury. By ensuring the environment is safe, the risk of falls and subsequent injuries is minimized. Choice B, assessing the client's functional status, is important but not the primary intervention. Choice C, encouraging the client to rest, may not address the underlying issue of fall risk. Choice D, encouraging the client to ambulate, may increase the risk of falls for someone with a history of falls. It is crucial to prioritize safety by modifying the environment to prevent falls.

Question 3 of 9

What is the appropriate response when a client asks about the safety of drinking alcohol during pregnancy?

Correct Answer: A

Rationale: The correct answer is A because the amount of alcohol that is safe during pregnancy is unknown. It is recommended to avoid alcohol completely to prevent any potential harm to the developing fetus. B is incorrect because there is no known safe level of alcohol consumption during pregnancy. C is incorrect as any amount of alcohol can potentially harm the fetus. D is incorrect as using alcohol to relax during pregnancy is not recommended due to the associated risks.

Question 4 of 9

A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions?

Correct Answer: B

Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.

Question 5 of 9

What is the best method for a nurse to assess a client's pain level?

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Question 6 of 9

A nurse is caring for a patient who is receiving chemotherapy. The nurse should prioritize monitoring for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.

Question 7 of 9

Which food is an example of a complete protein?

Correct Answer: B

Rationale: The correct answer is B: Eggs. Eggs are considered a complete protein because they contain all nine essential amino acids required by the body. These amino acids are necessary for various bodily functions, such as muscle growth and repair. Corn (A), peanuts (C), and sunflower seeds (D) are incomplete proteins as they lack one or more essential amino acids. Therefore, eggs are the best choice for a complete protein source compared to the other options provided.

Question 8 of 9

A nurse is providing teaching to a patient with type 2 diabetes. Which of the following should the nurse emphasize as the most important factor in managing the condition?

Correct Answer: A

Rationale: The correct answer is A: Monitoring blood glucose levels regularly. This is crucial in managing type 2 diabetes because it helps the patient understand how their body responds to food, medication, and activity. By tracking blood glucose levels, the patient can make informed decisions about their diet, medication, and lifestyle choices. This proactive approach enables early detection of fluctuations in blood sugar levels, allowing for prompt adjustments to prevent complications. Summary: - Choice A is correct as monitoring blood glucose levels is essential for managing type 2 diabetes. - Choice B is important but secondary to monitoring blood glucose levels. - Choice C is beneficial for managing diabetes but not as critical as blood glucose monitoring. - Choice D, following a low-carb diet, can be helpful but may not be the most important factor in managing the condition.

Question 9 of 9

What should the nurse do first when a client has a suspected fracture?

Correct Answer: A

Rationale: The correct answer is A: Apply a splint. This is the first step because immobilizing the affected limb helps prevent further injury and reduces pain. Administering fluids (B) and oxygen (C) are important but not the priority in this situation. Elevating the limb (D) can wait until the fracture is stabilized.

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