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A cl ient presents at a community-based cl inic wi th complaints of shortness of breath, headache, often uses a gasol ine-powered pressure w asher to clean equipment and farm bui ldi ngs. Which type of poi so ni ng i s the most l ikel y etiology of t his cli ent's symptoms?
- A. asbestos
- B. si l ica dust
- C. histopl asmosi s
- D. carbon monoxi de -
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?
- A. Apical pulse of 58 beats per minute.
- B. Serum potassium level of 3.0 mEq/L.
- C. Blood pressure of 140/90 mm Hg.
- D. Client reports seeing halos around lights.
Correct Answer: D
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.
The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct Answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?
- A. suggest the client installs a bedside commode
- B. assist the client in modifying the home environment
- C. refer the client to an occupational therapist
- D. educate the client on mobility aids
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.