Nokea
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which findings should the nurse identify as adverse effects of this medication? (Select all that apply.)
- A. Visual hallucinations
- B. Tachycardia
- C. Decreased cravings
- D. Impaired judgment
- E. Increased thirst
Correct Answer: A,D
Rationale: Varenicline has a black box warning for causing behavioral changes, including visual hallucinations and impaired judgment. Tachycardia and increased thirst are not associated adverse effects, while decreased cravings is a desired therapeutic effect.
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A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?
- A. Assistance with activities of daily living
- B. Assess the client's oxygen saturation levels
- C. Oxygen therapy at 2 liters per nasal cannula
- D. Complete bedrest with frequent repositioning
Correct Answer: A
Rationale: Dyspnea with activity intolerance, such as stopping multiple times while climbing stairs, indicates functional limitation (class III). Assistance with activities of daily living supports the client's needs without restricting activity unnecessarily. Oxygen therapy or bedrest may not be indicated unless hypoxia or severe limitation is present.
While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)
- A. What response do you have when you eat avocados?
- B. I will remove any avocados that are on your food tray
- C. Ask about the last time you ate avocados
- D. I will document this in your record so all of your providers will know
- E. Have you ever been treated for this allergic reaction?
Correct Answer: A,D,E
Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate
- B. Crackles are heard in the trachea. The nurse encourages the client to cough perfectly
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply
Correct Answer: C
Rationale: Wheezes indicate narrowed airways, and an inhaled bronchodilator is the appropriate intervention to open air passages. Hollow sounds over the trachea are normal, crackles may require diuresis rather than coughing, and vesicular sounds in the periphery are normal, requiring no intervention.
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds with aids
- C. Productive cough
- D. Incisional discomfort
Correct Answer: B
Rationale: Absent breath sounds may indicate a pneumothorax, a life-threatening complication post-lung biopsy requiring immediate action. Increased temperature, productive cough, and incisional discomfort are not immediately life-threatening.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
- A. Measure oxygen saturation after a 12-minute walk
- B. Verify that the client understands all possible complications
- C. Explain the procedure in detail to the client and the family
- D. Validate that informed consent has been given to the client
Correct Answer: D
Rationale: Validating informed consent is critical before an invasive procedure like thoracentesis to ensure the client is aware of risks and agrees to the procedure. Explaining the procedure and verifying complications are typically the physician's responsibility, and a 12-minute walk is not relevant.