Nokea
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
- A. Administer the first dose of antibiotic therapy
- B. Observe the color, consistency, and amount of sputum
- C. Encourage the client to consume plenty of warm liquids
- D. Send the specimen to the lab for analysis
Correct Answer: B
Rationale: Observing the color, consistency, and amount of sputum helps in assessing the nature of the infection and guides further treatment. Sending the specimen to the lab is important but not the first action.
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Treatment options in the management of an intussusception include:
- A. Contrast enema
- B. Air enema
- C. Water enema
- D. Open surgery
Correct Answer: B
Rationale: Air enema is a common non-surgical treatment for intussusception. Contrast enema and open surgery are also options, but air enema is often preferred.
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
Decreased DLCO is seen with:
- A. Increased CO in circulation
- B. Anaemia
- C. Pulmonary fibrosis
- D. Exercise
Correct Answer: C
Rationale: Pulmonary fibrosis: Decreased diffusing capacity for carbon monoxide (DLCO) is a hallmark of pulmonary fibrosis, where lung tissue becomes scarred, reducing its ability to transfer gases.
The lower limit of pulse rate in neonate at rest is
- A. 50/min
- B. 60/min
- C. 70/min
- D. 80/min
Correct Answer: B
Rationale: The lower limit of normal pulse rate in neonates at rest is typically around 60 beats/min.
Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant?
- A. Promoting fluid restriction
- B. Feeding a low-salt formula
- C. Feeding in semi-Fowler position
- D. Encouraging breast milk
Correct Answer: C
Rationale: Feeding in a more upright position helps fluid drain from the lungs, improving breathing and reducing cardiac workload.