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A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma?
- A. Pindolol (Visken)
- B. Carteolol (Ocupress)
- C. Metoprolol tartrate (Lopressor)
- D. Propranolol hydrochloride (Inderal)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?
- A. review the child's medical folder for a list of allergies
- B. instruct the child's parents to begin treatment with
- C. advise the children's parents to obtain a medical evaluation of the child
- D. none of the above
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is caring for a client with a chest tube. Which intervention is most important to include in the plan of care?
- A. Maintain continuous suction on the chest tube.
- B. Clamp the chest tube during client movement.
- C. Ensure that the chest tube is clamped for at least 8 hours each day.
- D. Keep the collection chamber below the level of the chest.
Correct Answer: D
Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.
A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Place the client in a high Fowler's position.
- C. Obtain a 12-lead electrocardiogram (ECG).
- D. Administer intravenous furosemide (Lasix).
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While assessing a client receiving a blood transfusion, which finding requires immediate intervention?
- A. Temperature of 100.4°F (38°C).
- B. Blood pressure of 110/70 mm Hg.
- C. Heart rate of 90 beats per minute.
- D. Complaints of feeling cold.
Correct Answer: C
Rationale: A heart rate of 90 beats per minute requires immediate intervention when assessing a client receiving a blood transfusion. This finding can indicate a potential transfusion reaction, such as a hemolytic reaction or fluid overload, which requires prompt evaluation and management to prevent serious complications. While a temperature of 100.4°F (38°C) may indicate a mild fever, it is not typically an immediate concern during a blood transfusion. A blood pressure of 110/70 mm Hg is within the normal range, and complaints of feeling cold can be addressed but do not indicate an urgent need for intervention compared to the critical nature of a potential transfusion reaction indicated by an elevated heart rate.
Which intervention by the community health nurse is an example of a secondary level of prevention?
- A. providing a needle exchange program at a community mental health clinic
- B. developing an educational program for clients with diabetes mellitus
- C. administering influenza vaccines to residents of a nursing home
- D. initiating contact notifications for sexual partners of an HIV client
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.