#1
Which condition is a potential complication of immobility in bedridden patients?
Pneumonia
ExplanationStagnation of respiratory secretions can lead to pneumonia.
#2
Which nursing intervention is appropriate for a patient with impaired skin integrity?
Implementing a turning schedule and using pressure-relieving devices
ExplanationPrevention of pressure ulcers through proper positioning and support.
#3
Which nursing intervention is appropriate for a patient experiencing chest pain?
Assessing vital signs and contacting the healthcare provider
ExplanationImmediate assessment to identify potential cardiac issues.
#4
What is the priority nursing action for a patient with acute respiratory distress?
Administering oxygen therapy
ExplanationEnsuring adequate oxygenation to support respiratory function.
#5
Which laboratory result requires immediate action for a patient on warfarin therapy?
INR of 5.0
ExplanationIndicates increased risk of bleeding, necessitating adjustment of anticoagulation therapy.
#6
What is the priority nursing action for a patient admitted with diabetic ketoacidosis?
Administering regular insulin via IV infusion
ExplanationTo lower blood glucose levels and address metabolic acidosis.
#7
Which action is essential when caring for a patient with a chest tube drainage system?
Keeping the drainage system below the level of the chest
ExplanationPrevents backflow of fluid and air into the chest cavity.
#8
Which assessment finding requires immediate intervention for a patient receiving continuous enteral feeding?
Residual volume greater than 100 mL
ExplanationIndicates inadequate digestion or absorption, risking aspiration.
#9
What is the priority nursing intervention for a patient experiencing a seizure?
Ensuring a patent airway and protecting the patient from injury
ExplanationSafety measures to prevent harm during seizure activity.
#10
Which assessment finding requires immediate intervention in a patient with a nasogastric tube?
Abdominal distension and absent bowel sounds
ExplanationIndicative of potential bowel obstruction or other complications.
#11
What is the priority nursing intervention for a patient with a central venous catheter experiencing signs of infection?
Obtaining cultures from the catheter and initiating antibiotic therapy as ordered
ExplanationEarly identification and treatment of infection to prevent systemic complications.
#12
Which intervention is essential to prevent ventilator-associated pneumonia in a mechanically ventilated patient?
Maintaining the head of the bed at 30 to 45 degrees
ExplanationReduces risk of aspiration and improves lung expansion.
#13
What is the priority nursing intervention for a patient experiencing anaphylaxis?
Administering epinephrine
ExplanationCounteracts severe allergic reactions to prevent further complications.
#14
What is the priority nursing intervention for a patient experiencing a hypertensive crisis?
Administering IV antihypertensive medication as ordered
ExplanationTo rapidly lower blood pressure and prevent end-organ damage.