Nokea
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. The nurse should first:
- A. Administer bronchodilators as ordered.
- B. Initiate oxygen therapy as ordered.
- C. Start I.V. fluids as ordered.
- D. Teach the client diaphragmatic breathing.
Correct Answer: B
Rationale: In an acute asthma attack with severe dyspnea, initiating oxygen therapy corrects hypoxemia, a priority. Bronchodilators are critical but secondary to oxygenation. I.V. fluids and breathing techniques are supportive but not immediate priorities.
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A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
The primary goal for the client with Buerger's disease is to prevent:
- A. Embolus formation
- B. Fat embolus formation
- C. Thrombophlebitis
- D. Gangrene
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
- A. Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.
- B. Activity level is determined by the client's tolerance; she can be as active as she wishes.
- C. Activity level will be restricted for several months, so she should plan on being sedentary.
- D. Activity level can return to normal and may include regular aerobic exercises.
Correct Answer: A
Rationale: Gradual resumption of activity over 5 to 6 weeks allows the retina to heal properly while minimizing the risk of re-detachment or complications.
The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.