Nokea
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to:
- A. Prevent insensible water loss
- B. Provide a moist environment with oxygen at 30%
- C. Prevent dehydration and reduce fever
- D. Liquefy secretions and relieve laryngeal spasm
Correct Answer: D
Rationale: High-humidity tents in croup moisten airways, liquefying secretions and relieving laryngeal spasms, easing breathing. Oxygen levels are not necessarily 30%, and dehydration or fever is secondary.
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A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Platelet count
- B. Prothrombin time (PT/INR)
- C. Hemoglobin
- D. Serum potassium
Correct Answer: B
Rationale: Warfarin affects clotting, requiring monitoring of PT/INR to ensure therapeutic anticoagulation. Platelets (A), hemoglobin (C), and potassium (D) are not directly affected.
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
- A. Fried chicken
- B. Eggs
- C. Tapioca
- D. Cabbage
Correct Answer: C
Rationale: Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. Eggs will cause odor-producing stools in individuals with all types of GI ostomies. Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness.'
- B. Just don't pay attention to the voices. They'll go away after some medication.'
- C. You can't leave here. This unit is locked and the doctor has not ordered your discharge.'
- D. We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.
The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Administration of oxygen at 2 L/min
- C. Needle decompression
- D. Bronchodilator therapy
Correct Answer: C
Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.