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The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct Answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
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A client with a history of hypertension is admitted with a blood pressure of 200/120 mm Hg. Which medication should the nurse prepare to administer?
- A. Metoprolol (Lopressor).
- B. Furosemide (Lasix).
- C. Lisinopril (Zestril).
- D. Nitroprusside (Nipride).
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with hyperthyroidism is receiving radioactive iodine therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid close contact with pregnant women and children for a few days.
- B. I may experience dry mouth and taste changes for a few days.
- C. I may experience some neck swelling.
- D. I may experience some neck swelling.
Correct Answer: D
Rationale: The correct answer is 'D.' The client stating 'I may experience some neck swelling' does not indicate a need for further teaching since neck swelling is an expected side effect of radioactive iodine therapy. Choices A and B are correct statements as the client should avoid close contact with pregnant women and children for a few days due to radiation exposure, and dry mouth and taste changes are common side effects. Choice C is redundant with choice D, making D the correct answer.
The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?
- A. Hyperpigmentation of the skin.
- B. Low blood pressure.
- C. Nausea and vomiting.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.
The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?
- A. instruct the client to dispose of the expired medications
- B. review the client's current medication regimen
- C. contact the client's healthcare provider
- D. educate the client on the dangers of taking expired medications
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.