Nokea
A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
- A. It produces greater blood oxygen levels.
- B. It is easier to breathe through the nose.
- C. The nares humidify, warm, and filter the air.
- D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Correct Answer: C
Rationale: The nares humidify, warm, and filter air, improving its quality for respiration.
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An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen?
- A. In the morning right after he awakens
- B. Immediately after breakfast
- C. Two hours after eating
- D. Shortly before he retires for the evening
Correct Answer: A
Rationale: The sputum has collected during the night, making it most concentrated and ideal for culture early in the morning.
When the physician prescribes the first-generation antihistamine for the client's symptomatic relief, the nurse appropriately advises the client that first-generation antihistamines are associated with which side effect?
- A. Weight loss
- B. Constipation
- C. Drowsiness
- D. Depression
Correct Answer: C
Rationale: First-generation antihistamines cross the blood-brain barrier, often causing drowsiness as a common side effect.
The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss?
- A. Instruct the children to always keep a tissue or handkerchief with them.
- B. Explain that children current with immunizations will not get a cold.
- C. Tell the children they should go to the doctor if they get a cold.
- D. Demonstrate to the students how to wash hands correctly.
Correct Answer: D
Rationale: Handwashing (D) is the most effective way to prevent cold transmission. Tissues (A) are secondary, immunizations (B) don’t prevent colds, and doctor visits (C) are unnecessary for most colds.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
Which nursing assessment data support that the client has experienced a pulmonary embolism?
- A. Calf pain with dorsiflexion of the foot.
- B. Sudden onset of chest pain and dyspnea.
- C. Left-sided chest pain and diaphoresis.
- D. Bilateral crackles and low-grade fever.
Correct Answer: B
Rationale: Sudden chest pain and dyspnea (B) are classic PE symptoms from hypoxia. Calf pain (A) suggests DVT, left-sided pain (C) suggests MI, and crackles/fever (D) suggest pneumonia.