Nokea
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
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What is an example of a pertinent negative finding during a physical examination?
- A. Chest pain that does not radiate to the arm
- B. Elevated blood pressure in a patient with hypertension
- C. Pupils that are equal and react to light and accommodation
- D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A
Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.
What are the factors that interfere with a client’s learning capacity? How can receptiveness to learning be increased?
- A. Stress,fatigue and lack of interest; create a supportive environment.
- B. Lack of resources; provide more materials.
- C. Cultural differences; adapt teaching methods.
- D. None of the above.
Correct Answer: A
Rationale: Factors like stress and fatigue hinder learning. Creating a supportive, stress-free environment enhances receptiveness.
Which type of therapy helps clients alter irrational thinking and replace negative self-statements with positive ones?
- A. Desensitization therapy
- B. Behavioral therapy
- C. Cognitive therapy
- D. Psychobiologic therapy
Correct Answer: C
Rationale: Cognitive therapy focuses on identifying and challenging irrational beliefs, helping clients develop healthier thought patterns.
A patient with sickle cell anemia will be given supplemental oxygen and which of the following?
- A. IV fluids to adequately hydrate.
- B. Narcotic pain management when pain is severe.
- C. Transfusion of red blood cells to correct anemia.
- D. All of the above.
Correct Answer: D
Rationale: Sickle cell anemia patients often require comprehensive treatment including hydration, pain management, and blood transfusions to manage complications.
Which step in the chain of infection refers to how a pathogen is transferred or moved from its reservoir to the susceptible host?
- A. Reservoir
- B. Portal of entry
- C. Means of transmission
- D. Susceptible host
Correct Answer: C
Rationale: The correct answer is C because the means of transmission describes how pathogens move from the reservoir to the host.