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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When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?
- A. Excessive growth
- B. Cognitive impairment
- C. Damage to the nervous system
- D. Damage to the urinary system
Correct Answer: B
Rationale: The correct answer is B: Cognitive impairment. The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. Excessive growth (Choice A) is not a common complication of hypothyroidism in infants. Damage to the nervous system (Choice C) and damage to the urinary system (Choice D) are not typically associated with untreated hypothyroidism in infants.
Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?
- A. Risk for infection related to thrombolysis.
- B. Risk for fluid volume deficit related to thrombolysis.
- C. Risk for impaired skin integrity related to thrombolysis.
- D. Risk for injury related to effects of thrombolysis.
Correct Answer: D
Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.
An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?
- A. Obtain a wound specimen for culture.
- B. Initiate an infusion of intravenous (IV) fluids.
- C. Transfer the client to the ICU.
- D. Assess the client's core temperature.
Correct Answer: B
Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.
What most influences the severity of respiratory distress syndrome (RDS)?
- A. Poor cough and gag reflex
- B. The gestational age at birth
- C. Administering high concentrations of oxygen
- D. The sex of the infant
Correct Answer: B
Rationale: The correct answer is B. The gestational age at birth most influences the severity of respiratory distress syndrome (RDS). RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low-birth weight infants. Therefore, the gestational age at birth is a key factor in determining the likelihood and severity of RDS. Choices A, C, and D are incorrect as they do not directly relate to the primary factor influencing the severity of RDS.
An 82-year-old female client with type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. What should the nurse recommend?
- A. Seek routine nail care with a podiatrist.
- B. Encourage monthly pedicures at a nail salon.
- C. Soak feet for 10 minutes before cutting nails.
- D. Ask a family member to cut toenails.
Correct Answer: A
Rationale: For an 82-year-old female client with type 2 diabetes and degenerative arthritis, the nurse should recommend seeking routine nail care with a podiatrist. This is crucial to ensure proper and safe toenail care, reducing the risk of injury and infection, which is especially important for diabetic clients. Encouraging monthly pedicures at a nail salon (choice B) may not address the underlying issues related to diabetes and arthritis. Soaking feet for 10 minutes before cutting nails (choice C) may help soften the nails but does not address the difficulty the client faces in cutting them. Asking a family member to cut toenails (choice D) may not guarantee the expertise needed for proper diabetic foot care, which a podiatrist can provide.