#1
Which of the following is a priority nursing intervention for a client experiencing a myocardial infarction (MI)?
Assessing vital signs
ExplanationAssessing vital signs is crucial for monitoring the client's condition and identifying any changes.
#2
What is the primary purpose of administering heparin to a client?
To prevent blood clot formation
ExplanationHeparin helps prevent the formation of blood clots, reducing the risk of complications such as pulmonary embolism.
#3
What is a common symptom of hypoglycemia?
Diaphoresis
ExplanationDiaphoresis, or excessive sweating, is a common symptom of hypoglycemia due to the body's stress response.
#4
What is the priority nursing action for a client experiencing anaphylaxis?
Ensuring a patent airway
ExplanationEnsuring a patent airway is crucial in anaphylaxis to prevent respiratory compromise and maintain oxygenation.
#5
What is a potential complication of prolonged immobility in a hospitalized client?
Increased risk of falls
ExplanationProlonged immobility can lead to muscle weakness and decreased balance, increasing the risk of falls.
#6
Which assessment finding indicates a potential complication of intravenous (IV) therapy?
Decreased urine output
ExplanationDecreased urine output may indicate inadequate fluid volume or renal complications related to IV therapy.
#7
What is a potential complication of an indwelling urinary catheter?
Increased risk of bladder distention
ExplanationIndwelling urinary catheters can increase the risk of bladder distention, urinary tract infections, and other complications.
#8
Which assessment finding suggests a client is experiencing fluid volume deficit?
Hypotension
ExplanationHypotension, or low blood pressure, can indicate fluid volume deficit due to decreased circulating blood volume.
#9
What nursing intervention is appropriate for a client with respiratory distress?
Administering oxygen therapy
ExplanationAdministering oxygen therapy helps improve oxygenation and alleviate respiratory distress in clients.
#10
What is a key intervention for preventing aspiration in a client with dysphagia?
Thickening liquids
ExplanationThickening liquids helps reduce the risk of aspiration in clients with dysphagia by making them easier to swallow safely.
#11
What is a priority nursing intervention for a client with a nasogastric tube?
Securing the tube to prevent dislodgement
ExplanationSecuring the nasogastric tube helps prevent accidental dislodgement, which can lead to complications such as aspiration.
#12
What is a priority nursing intervention for a client with a pressure injury?
Turning the client every 2 hours
ExplanationRegularly turning the client helps relieve pressure on vulnerable areas, promoting wound healing and preventing further tissue damage.