#1
Which of the following is a priority nursing intervention for a patient experiencing difficulty breathing?
Providing oxygen therapy
ExplanationPriority intervention to improve oxygenation in respiratory distress.
#2
Which nursing intervention is appropriate for a patient experiencing an acute asthma exacerbation?
Administering a bronchodilator
ExplanationRelieves bronchoconstriction and improves airflow in acute asthma attack.
#3
Which nursing intervention is appropriate for a patient experiencing hypoglycemia?
Administering a sugary drink or snack
ExplanationRapidly raises blood glucose levels to alleviate hypoglycemic symptoms.
#4
A patient is receiving intravenous (IV) heparin therapy for deep vein thrombosis (DVT). What is the priority nursing intervention?
Monitoring partial thromboplastin time (PTT)
ExplanationEnsures therapeutic anticoagulation and prevents bleeding complications.
#5
A patient with a head injury is at risk for increased intracranial pressure (ICP). What nursing intervention helps reduce ICP?
Maintaining a head-of-bed elevation of 30 degrees
ExplanationPromotes venous drainage and reduces cerebral edema, lowering ICP.
#6
When prioritizing nursing care, which patient should the nurse attend to first?
A patient with a history of hypertension who is complaining of a headache
ExplanationAddresses potential life-threatening condition of hypertensive crisis.
#7
A patient with pneumonia is receiving antibiotics. What is the nurse's priority intervention?
Monitoring for adverse drug reactions
ExplanationCrucial to ensure patient safety during antibiotic therapy.
#8
A patient with heart failure is prescribed a low-sodium diet. Which meal selection by the patient indicates understanding of dietary restrictions?
Grilled chicken salad with vinaigrette dressing
ExplanationLow sodium and healthy choice, aligning with dietary recommendations.
#9
During an initial assessment of a newborn, which finding requires immediate nursing intervention?
Cyanotic hands and feet
ExplanationIndicates potential respiratory or circulatory compromise requiring immediate attention.
#10
A patient is scheduled for surgery in the morning and needs preoperative teaching. When is the best time for the nurse to provide this teaching?
Early in the morning before breakfast
ExplanationAllows ample time for comprehension and minimizes interference from other activities.
#11
A patient with sepsis is hypotensive and tachycardic. What is the priority nursing intervention?
Administering IV fluids
ExplanationCritical for fluid resuscitation and hemodynamic stabilization in septic shock.
#12
A postoperative patient is at risk for deep vein thrombosis (DVT). What is the priority nursing intervention?
Encouraging ambulation
ExplanationReduces stasis and lowers the risk of thrombus formation postoperatively.
#13
A patient with diabetes mellitus is at risk for foot ulcers. What is the priority nursing intervention?
Teaching proper foot care
ExplanationPrevents complications and promotes foot health, crucial for patients with diabetes.
#14
A patient with a history of asthma is prescribed a metered-dose inhaler (MDI) with a corticosteroid. What teaching should the nurse provide?
The mouth should be rinsed after using the inhaler
ExplanationReduces the risk of oral thrush, a common side effect of inhaled corticosteroids.
#15
A patient with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy. What teaching should the nurse provide regarding oxygen use?
Oxygen flow rate should be adjusted based on symptoms
ExplanationEnsures appropriate oxygen titration, preventing oxygen toxicity and worsening hypercapnia.