Nokea
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucus, 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 medications occur
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: A
Rationale: Increasing fluid intake is crucial as it helps to thin mucus secretions, making them easier to expectorate. This can alleviate the client's symptoms of shortness of breath and productive cough. Option B is not the most important action in this scenario, as it does not directly address the client's respiratory distress. Option C, while important, focuses on medication side effects rather than addressing the immediate breathing difficulties. Option D, teaching anxiety reduction methods, is not the priority when the client's main concern is respiratory distress.
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The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?
- A. When the fever dissipates
- B. After the incubation period
- C. When the lesions have healed
- D. When the lesions are crusted over
Correct Answer: D
Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?
- A. Palpate for abdominal distention
- B. Send fluid to the lab for analysis
- C. Continue to monitor the fluid output
- D. Clamp the drainage tube for 5 minutes
Correct Answer: C
Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.
A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?
- A. Use the inhaler only before bedtime
- B. Shake the inhaler well before use
- C. Exhale fully before inhaling the medication
- D. Take two puffs every hour
Correct Answer: B
Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.
In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?
- A. Yellow.
- B. Black.
- C. Red.
- D. Green.
Correct Answer: A
Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.
The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
- A. Morning headaches
- B. Pain for 3 consecutive months
- C. Febrile episodes in the late afternoon
- D. Diaphoresis when attacks occur
Correct Answer: B
Rationale: The correct answer is B: Pain for 3 consecutive months. Recurrent abdominal pain (RAP) is characterized by abdominal pain that occurs at least once per week for at least 2 months before diagnosis. Choosing option A is incorrect since morning headaches are not a common characteristic of RAP. Option C is incorrect because febrile episodes in the late afternoon are not typically associated with RAP. Option D is incorrect as diaphoresis (excessive sweating) when attacks occur is not a common finding in RAP.