Nokea
Which of the following instructions should the nurse include?
- A. Perform chest percussion and postural drainage at least twice daily.
- B. Restrict intake of foods that contain gluten.
- C. Administer pancreatic enzymes on an empty stomach.
- D. Use a nebulizer to administer a bronchodilator fallowing airway clearance therapy.
Correct Answer: A
Rationale: The correct answer is A: Perform chest percussion and postural drainage at least twice daily. Chest percussion and postural drainage are essential airway clearance techniques for patients with cystic fibrosis to help mobilize and clear mucus from the lungs. Performing these techniques at least twice daily helps to prevent mucus buildup, reduce the risk of infections, and improve lung function. Restricting gluten intake (B) is not specific to cystic fibrosis management. Administering pancreatic enzymes on an empty stomach (C) is important for patients with cystic fibrosis to aid in digestion, but it is not directly related to chest physiotherapy. Using a nebulizer after airway clearance therapy (D) may be beneficial, but the primary focus should be on chest physiotherapy as the initial intervention for mucus clearance.
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For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
- A. Hypercapnia
- B. Muscle rigidity
- C. Tachycardia
- D. Urticaria
- E. Wheezes
Correct Answer:
Rationale: Rationales provided within the question context.
Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
Which of the following instructions should the nurse include in the teaching?
- A. Place tongue on the mouthpiece of the meter
- B. Maintain a semi-Fowler's position during testing
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D because blowing into the meter as hard and quickly as possible ensures accurate lung function test results. This instruction ensures a consistent and forceful flow of air, which is crucial for reliable readings. Option A is incorrect because the tongue should not be placed on the mouthpiece, as this can affect the accuracy of the test. Option B is incorrect as maintaining a semi-Fowler's position is not necessary for this test. Option C is incorrect because recording the average of the readings is not a step in the actual testing process.
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.
Which of the following findings require follow-up?
- A. 30-year-old client at 33 weeks gestation, Gravida 4 Para 3
- B. CBC and urinalysis collected and sent to lab.
- C. Maternal blood type: Rh+
- D. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- E. Client reports lower back pain and pinkish vaginal discharge.
- F. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds,
- G. FHR baseline 145, minimal variability.
Correct Answer: E,F,G
Rationale: The correct answers are E, F, and G because they indicate potential complications during pregnancy.
E: Lower back pain and pinkish vaginal discharge can be signs of preterm labor or placental issues, requiring immediate follow-up.
F: Uterine contractions every 8 minutes, strong palpation, and duration 30 seconds suggest active labor, needing monitoring for progression.
G: Fetal heart rate (FHR) baseline of 145 with minimal variability may indicate fetal distress, necessitating further assessment.
Other choices are routine findings or do not pose immediate risks, such as A (normal obstetric history), B (routine lab tests), C (Rh+ blood type is common), and D (history of preterm birth but no current concerns).