Nokea
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.
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Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) 2 days ago?
- A. Sitting in the bedside chair for 15 minutes three times a day
- B. Remaining on strict bed rest with bedside commode privileges
- C. Ambulating in the room and hall as tolerated
- D. Sitting on the bedside for 5 minutes three times a day with assistance
Correct Answer: A
Rationale: Sitting in a chair for short periods is appropriate 2 days post-MI to promote circulation and prevent complications, while ambulation is too strenuous.
A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
- A. call the physician and ask her to prescribe a different medication.
- B. work with the client on alternative pain relief measures such as guided imagery.
- C. administer the next dose of pain medication, but observe the client swallow it to ensure she is really taking the medication.
- D. complete a full head-to-toe assessment on the client.
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?
- A. Hematocrit
- B. Creatinine
- C. White blood cell count
- D. Erythrocyte count
Correct Answer: B
Rationale: Creatinine levels indicate renal function, critical to monitor before administering gentamycin, which is nephrotoxic.
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
- A. Antivirals
- B. Antibiotics
- C. Immunosuppressants
- D. Analgesics
Correct Answer: C
Rationale: Immunosuppressants, such as cyclosporine, prevent the immune system from forming antibodies against the transplanted heart.
A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?
- A. Apply direct pressure to the site
- B. Check the pedal pulses on the right leg
- C. Notify the physician
- D. Turn the client to the prone position
Correct Answer: A
Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.