Nokea
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?
- A. Flushing
- B. Dyspnea
- C. Tachycardia
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. Flushing (choice A) is not a typical side effect of albuterol. Dyspnea (choice B) refers to difficulty breathing, which is a symptom of asthma but not a common side effect of albuterol. Hypotension (choice D) is low blood pressure, which is not a common side effect associated with albuterol use.
You may also like to solve these questions
Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: C
Rationale: The correct answer is C: Implementation. Implementation in nursing care involves the actual performance and supervision of the planned therapeutic and preventive procedures for a patient. Evaluation (choice A) is the step where the effectiveness of the interventions is assessed. Planning (choice B) is the phase where the nursing care plan is developed based on the assessment. Assessment (choice D) is the initial step in the nursing process, involving data collection and analysis to determine the patient's needs.
The nurse writes a problem of "potential for complication related to ovarian hyperstimulation" for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?
- A. Instruct the client to delay intercourse until menses
- B. Schedule the client for frequent pelvic sonograms
- C. Explain that the infusion therapy will take 21 days
- D. Discuss that this may cause an ectopic pregnancy
Correct Answer: B
Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (Choice A) is not directly related to monitoring for ovarian hyperstimulation. Explaining the duration of infusion therapy (Choice C) is not relevant to monitoring for this specific complication. Discussing the risk of ectopic pregnancy (Choice D) is important, but it is not the most appropriate intervention for monitoring ovarian hyperstimulation.
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
- B. Re-crossmatch the blood until the antibodies are identified
- C. Have the client sign a permit to receive uncrossmatched blood
- D. Have the unlicensed nursing assistant stay with the client
Correct Answer: A
Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.
Where do most peptic ulcers occur?
- A. Esophagus
- B. Stomach
- C. Duodenum
- D. Jejunum
Correct Answer: C
Rationale: Most peptic ulcers occur in the duodenum, particularly in cases of duodenal ulcers. Peptic ulcers are most commonly found in the duodenum or the first part of the small intestine. While ulcers can also occur in the esophagus and stomach, they are predominantly located in the duodenum. Therefore, options A, B, and D are incorrect.
Which situations are classified as natural disasters?
- A. Blizzards
- B. A, C
- C. Volcanic eruptions
- D. Structural collapse
Correct Answer: B
Rationale: The correct answer is B. Blizzards and volcanic eruptions are both examples of natural disasters caused by natural forces such as extreme weather conditions and tectonic activities. On the other hand, structural collapse is typically a result of man-made factors like poor construction or maintenance. Therefore, choices A, C, and D are incorrect as only blizzards and volcanic eruptions are classified as natural disasters.