Nokea
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on the heart tones heard?
- A. Administer a diuretic.
- B. Document the finding.
- C. Decrease the IV flow rate.
- D. Evaluate the client’s medications.
Correct Answer: B
Rationale: Documenting the findings is the appropriate action unless the heart tones indicate an abnormality requiring intervention.
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A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
- A. Administer the first dose of antibiotic therapy
- B. Observe the color, consistency, and amount of sputum
- C. Encourage the client to consume plenty of warm liquids
- D. Send the specimen to the lab for analysis
Correct Answer: B
Rationale: Observing the color, consistency, and amount of sputum helps in assessing the nature of the infection and guides further treatment. Sending the specimen to the lab is important but not the first action.
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Auscultate for presence of bowel sounds.
- B. Monitor hemoglobin and hematocrit
- C. Encourage turning and deep breathing
- D. Administer IV antibiotics as prescribed.
Correct Answer: D
Rationale: Administering IV antibiotics promptly is critical to treat the infection and prevent complications in acute pyelonephritis.
Causes of non-bloody diarrhoea include:
- A. Shigella dysentery
- B. Campylobacter jejuni
- C. Giardia lamblia
- D. Salmonella
Correct Answer: C
Rationale: Giardia lamblia is a common cause of non-bloody diarrhoea. Shigella and Campylobacter typically cause bloody diarrhoea.
The routine investigation of a 4-year-old with an uncomplicated UTI involves:
- A. Renal ultrasound scan
- B. Micturating cystogram
- C. DMSA (dimercaptosuccinic acid) scan
- D. DTP scan
Correct Answer: A
Rationale: A renal ultrasound scan is a standard initial investigation for a child with an uncomplicated UTI to assess for structural abnormalities.
Hypertrophic obstructive cardiomyopathy
- A. Causes LV outflow tract obstruction
- B. Occurs after adenoviral infection
- C. Commonly occurs in infancy
- D. Double apical impulse
Correct Answer: A
Rationale: Hypertrophic obstructive cardiomyopathy primarily causes left ventricular outflow tract obstruction.