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When assessing a client with acute asthma, the nurse is most likely to obtain which finding?
- A. Pursed lip breathing and clubbing of fingers
- B. Fever and a high-pitched inspiratory stridor
- C. A short expiratory phase and hemoptysis
- D. Cough and musical breath sounds on expiration
Correct Answer: D
Rationale: When assessing a client with acute asthma, a cough and wheezing or musical breath sounds on expiration are typical findings. Pursed lip breathing and clubbing of fingers (choice A) are not common in acute asthma but could be seen in chronic respiratory conditions. Fever and high-pitched inspiratory stridor (choice B) are more indicative of croup or epiglottitis. A short expiratory phase and hemoptysis (choice C) are not typical findings in acute asthma.
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A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left-side paralysis
Correct Answer: B
Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.
A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?
- A. I am sorry, but your friend was killed in the accident.
- B. Right now you need to concentrate on getting well.
- C. Was the passenger in the car your friend?
- D. I think your friend is going to be all right.
Correct Answer: A
Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Advise the client to replace cooked foods with a variety of different nutritional supplements
- C. Assess the client's mucus membranes and report the findings to the healthcare provider
- D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
Correct Answer: A
Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.
A client with eczema is experiencing severe pruritus. Which PRN prescription should the nurse administer?
- A. Topical corticosteroid
- B. Topical scabicide
- C. Topical alcohol rub
- D. Transdermal analgesic
Correct Answer: A
Rationale: The correct answer is A: Topical corticosteroid. Topical corticosteroids are commonly used to manage itching in eczema by reducing inflammation and suppressing the immune response. In this case, for severe pruritus in eczema, a topical corticosteroid would be appropriate. Choice B, Topical scabicide, is used to treat scabies, not eczema. Choice C, Topical alcohol rub, is not typically used to manage pruritus in eczema. Choice D, Transdermal analgesic, is more for pain relief and not specifically targeted at managing itching associated with eczema.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct Answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.