Nokea
A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?
- A. Carbon monoxide poisoning
- B. Heat stroke
- C. Hypersensitivity reaction
- D. Oxygen toxicity
Correct Answer: A
Rationale: The correct answer is A: Carbon monoxide poisoning. When the furnace is turned on for the first time, it may release carbon monoxide, a colorless and odorless gas that can cause headaches and vertigo. Carbon monoxide binds to hemoglobin, reducing oxygen delivery to tissues, leading to symptoms. Heat stroke (B) is caused by prolonged exposure to high temperatures. Hypersensitivity reactions (C) involve the immune system's response to an allergen. Oxygen toxicity (D) occurs with prolonged exposure to high levels of oxygen.
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A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?
- A. Petechiae on the chest and abdomen
- B. WBC 16,000/mm3
- C. Negative throat culture
- D. Severe hyperemia of pharyngeal mucosa
Correct Answer: C
Rationale: The correct answer is C, negative throat culture. In viral pharyngitis, the infection is caused by a virus, not bacteria. Therefore, a throat culture would be negative as it tests for bacterial infection. Option A is incorrect as petechiae are more commonly seen in conditions like meningococcal sepsis. Option B is incorrect as a WBC count of 16,000/mm3 is more indicative of a bacterial infection. Option D is incorrect as severe hyperemia of the pharyngeal mucosa is more typical of bacterial pharyngitis, not viral.
What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.
Liz is an elderly woman brought in by concerned family members. After physical examination, she was diagnosed with dehydration. What assessment findings would you expect to see?
- A. Bradycardia,slowed respirations low body temperature and weight gain.
- B. Rales peripheral edema palpitations and diaphoresis.
- C. Tachypnea tachycardia hypotension poor skin turgor and decreased urinary output.
- D. Malaise lymphadenopathy fever shortness of breath and nausea.
Correct Answer: C
Rationale: The correct answer is Tachypnea, tachycardia, hypotension, poor skin turgor, and decreased urinary output (C). Dehydration leads to reduced blood volume, causing compensatory mechanisms like tachycardia and tachypnea. Poor skin turgor and decreased urinary output are classic signs of fluid loss.
Which of these tasks are appropriate to delegate to the LPN/LVN who is functioning under the supervision of an RN? (Choose all that apply.)
- A. Assess the sexual implications for a client with oculogenital type Chlamydia trachomatis.
- B. Administer sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis.
- C. Review handwashing and hygiene practices with clients who have eye infections.
- D. Show clients how to gently cleanse eyelid margins to remove crusting.
Correct Answer: B
Rationale: Administering medications is within the scope of practice for LPNs/LVNs under RN supervision.
A client is considering laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery. The nurse's response should be based upon the knowledge that laser surgery:
- A. has a smaller postoperative infection rate than routine surgery.
- B. will eliminate the need for preoperative sedation.
- C. will result in less operating time.
- D. generally eliminates problems and complications.
Correct Answer: A
Rationale: A lower postoperative infection rate has been documented as a result of laser therapy versus routine surgery. Clients who choose laser surgery will still need preoperative sedation to facilitate anxiety reduction. Operating time may actually increase in some laser surgeries. The client who chooses laser surgery must still be observed for postoperative complications.