Nokea
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Evaluate the urine for a strong odor.
- C. Test the urine for the presence of hematuria.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse assesses for systemic infection, such as pyelonephritis, which is urgent given the symptoms.
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Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?
- A. Methotrexate has less harmful side effects than aspirin.
- B. Methotrexate helps to reduce the side effects of the aspirin therapy.
- C. Methotrexate enhances the effectiveness of the aspirin.
- D. Methotrexate slows the disease progression while aspirin controls the symptoms.
Correct Answer: D
Rationale: Methotrexate slows RA progression, while aspirin manages symptoms, addressing both disease and comfort.
Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. The client reports that symptoms seem worse when outdoors and when exercising.
Correct Answer: A,B
Rationale: The ineffective use of the rescue inhaler indicates a severe asthma attack requiring intervention, and worsening symptoms with exercise suggest environmental triggers needing management.
The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, 'Penicillin 500,000 units/mL'. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- A. 0.4 mL
Correct Answer: A
Rationale: Calculation: 200,000 units ÷ 500,000 units/mL = 0.4 mL, ensuring accurate dosing.
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Impaired renal function related to pain.
- B. Acute pain related to renal calculus.
- C. Risk for aspiration related to vomiting.
- D. Nutritional deficit related to nausea.
Correct Answer: C
Rationale: Risk for aspiration is the highest priority due to the immediate threat of airway obstruction from vomiting.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Select another finger.
- B. Assess radial pulse volume.
- C. Collect the blood sample.
- D. Apply pressure to the site.
Correct Answer: D
Rationale: Applying pressure reduces engorgement, ensuring an accurate glucose sample and preventing trauma.