Nokea
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
- A. Increase the daily intake of oral fluids to liquefy secretions
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Call the clinic if undesirable side effects of mediations occur
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: A
Rationale: Increasing fluid intake helps to thin secretions, making them easier to expectorate and improving airway clearance.
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Which of the following is an example of humanized anti-human IL-6 receptor monoclonal antibody?
- A. Infliximab
- B. Adalimumab
- C. Tocilizumab
- D. Anakinra
Correct Answer: C
Rationale: Tocilizumab is a humanized monoclonal antibody that targets the IL-6 receptor, used in treating inflammatory conditions.
An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Assist with ambulation in the hallway
- B. Encourage active range of motion exercises
- C. Provide a bedside commode for toileting
- D. Teach to sleep in a side-laying position
Correct Answer: C
Rationale: Providing a bedside commode reduces the need for the client to walk to the bathroom, decreasing strain on the heart.
What is the most likely congenital heart lesion in a newborn with Trisomy 21?
- A. AVSD
- B. Tetralogy of Fallot
- C. Ventricular septal defect
- D. Pulmonary stenosis
Correct Answer: A
Rationale: Atrioventricular septal defect (AVSD) is highly associated with Trisomy 21 and is the most likely congenital heart lesion in these infants.
Which food is most important for the nurse to encourage a male client with osteomalacia to include in his daily diet?
- A. Fortified milk and cereals
- B. Lean red meat and poultry
- C. Fresh fruits and vegetables
- D. Whole grains and legumes
Correct Answer: A
Rationale: Fortified foods rich in vitamin D and calcium are crucial for the client with osteomalacia to help in bone mineralization.
Which action by the school nurse is important in the prevention of rheumatic fever?
- A. Encourage routine cholesterol screenings.
- B. Conduct routine blood pressure screenings.
- C. Refer children with sore throats for throat cultures.
- D. Recommend salicylates instead of acetaminophen for minor discomforts.
Correct Answer: C
Rationale: Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A β-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A β-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.