Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?
- A. Respiratory acidosis.
- B. Respiratory alkalosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: COPD with pneumonia can impair gas exchange, leading to CO2 retention and respiratory acidosis.
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The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
- A. Suctioning the tracheostomy as needed.
- B. Cleaning the tracheostomy site daily.
- C. Humidifying the inspired air.
- D. Securing the tracheostomy tube.
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative properties, making it appropriate if ordered for this purpose.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about medication management. Which of the following medications should the client expect to take?
- A. Methotrexate.
- B. Colchicine.
- C. Allopurinol.
- D. Probenecid.
Correct Answer: A
Rationale: Methotrexate is a disease-modifying antirheumatic drug (DMARD) commonly used for rheumatoid arthritis.
A client with a history of asthma reports increased wheezing. Which medication should the nurse prepare to administer?
- A. Prednisone.
- B. Albuterol.
- C. Montelukast.
- D. Cromolyn sodium.
Correct Answer: B
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm.