Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with respiratory distress. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position optimizes lung expansion and eases breathing in COPD.
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The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
- A. Noisy respirations.
- B. Pupillary constriction.
- C. Halitosis.
- D. Moist skin.
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy?
- A. Mouth breathing.
- B. Frequent swallowing.
- C. Requests for a drink.
- D. Increased pulse rate.
Correct Answer: B
Rationale: Frequent swallowing is the earliest sign of post-tonsillectomy hemorrhage, as the child swallows blood from the surgical site. Increased pulse rate may occur later.
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, 'How could God do this to me? I've never done anything wrong.' Which of the following responses by the nurse would be most appropriate at this time?
- A. God can handle your anger. It's okay.'
- B. I know you are angry. It's so hard to lose your baby.'
- C. It's not God's fault. It was an accident.'
- D. You're a strong person. You will get through this.'
Correct Answer: B
Rationale: Acknowledging the client's anger and the difficulty of the loss validates their emotions and provides empathetic support, which is most appropriate in this situation. Option A may dismiss the client's feelings, C shifts focus inappropriately, and D assumes strength without addressing the emotional impact.
How many mLs will you administer to the client after you use 3.3 mL of normal saline to reconstitute a medication that will yield 12 mg per mL and the doctor's order is as follows. Doctor's order: 25 mg of medication BID
- A. 1.9 mL
- B. 2.0 mL
- C. 2.5 mL
- D. 2.1 mL
Correct Answer: D
Rationale: To calculate: 25 mg ÷ 12 mg/mL = 2.083 mL, rounded to 2.1 mL for practical administration.