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A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client?
- A. Endotracheal intubation
- B. Paracentesis
- C. Thoracentesis
- D. Ventilation-perfusion scan
Correct Answer: C
Rationale: Thoracentesis removes fluid from the pleural space, relieving pressure on the lung and improving breathing in a large pleural effusion.
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A 9-year-old with type 1 diabetes takes insulin glargine and NPH regularly. While at school, the client becomes shaky, diaphoretic, and pale. What is the most appropriate action by the nurse?
- A. Administer scheduled dose of NPH insulin
- B. Give emergency glucagon IM injection
- C. Give peanut butter and crackers
- D. Provide 4 oz (120 mL) of a regular soft drink
Correct Answer: D
Rationale: Shakiness, diaphoresis, and pallor indicate hypoglycemia. Providing 15 grams of fast-acting carbohydrates, such as 4 oz of a regular soft drink, is the first-line treatment.
Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct Answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup.
A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
- A. Acknowledging the presence of the pain
- B. Elevating the stump on a pillow
- C. Applying a transcutaneous nerve stimulator unit (TENS)
- D. Rewrapping the stump
Correct Answer: C
Rationale: Applying a TENS unit can help relieve phantom limb pain by stimulating nerves and reducing pain signals. Acknowledging the pain is supportive but does not directly relieve it. Elevating the stump may help with swelling but not specifically phantom pain. Rewrapping the stump may provide comfort but is less effective than TENS for pain relief.
The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:
- A. Apply the eye ointment and eye drops together.
- B. Apply the eye drops, wait 5 minutes, and apply the ointment.
- C. Apply the eye ointment, wait 30 minutes, and apply the eye drops.
- D. Ask the pharmacist to supply the two medications in the same form.
Correct Answer: B
Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.
The nurse is reinforcing teaching with an adolescent client who has acne vulgaris. Which of the following information should the nurse reinforce? Select all that apply.
- A. A well-balanced diet can help support healthy skin.
- B. Antibacterial soap is harsh and can make your acne worse.
- C. Scrub whiteheads vigorously when washing your face twice daily.
- D. Squeezing or picking the lesions may increase the risk for infection and scarring.
- E. Use skin care products labeled as noncomedogenic to avoid clogging your skin pores.
Correct Answer: A,B,D,E
Rationale: A balanced diet (A), avoiding harsh soaps (B), not picking lesions (D), and using noncomedogenic products (E) promote skin health and prevent acne exacerbation.