Nokea
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. The client has decreased mucus production.
- B. The clients daily peak expiratory flow (PEF) measures 85% above personal best.
- C. The client has a respiratory rate of 24/min.
- D. The client reports no nighttime coughing.
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma. Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness. Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.
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A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?
- A. A client receiving chemotherapy for early-stage breast cancer.
- B. A client whose medications to manage Parkinsons disease are no longer effective.
- C. A client recovering from a total knee replacement.
- D. A client with seasonal allergies needing symptom relief.
Correct Answer: B
Rationale: The correct answer is B because the client with Parkinson's disease whose medications are no longer effective may benefit from the specialized care and symptom management provided by palliative care. Palliative care focuses on improving quality of life for individuals with serious illnesses by addressing physical, emotional, and spiritual needs. Referral is appropriate when symptoms are not adequately controlled. Choices A, C, and D do not require palliative care as they involve routine treatments or procedures that do not necessarily indicate the need for specialized palliative services.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect heavy bleeding for the next week.
- B. I will avoid using tampons for the next few weeks.
- C. I should resume sexual activity within 24 hours.
- D. I will avoid all physical activity for a month.
Correct Answer: B
Rationale: The correct answer is B: "I will avoid using tampons for the next few weeks." This statement indicates an understanding of the discharge teaching because using tampons can introduce bacteria into the healing cervix, increasing the risk of infection post-LEEP. Choosing this answer demonstrates knowledge of the importance of maintaining good hygiene and minimizing infection risk during the healing process.
Other choices are incorrect:
A: Expecting heavy bleeding for the next week is incorrect as heavy bleeding should decrease gradually.
C: Resuming sexual activity within 24 hours is incorrect as it can increase the risk of infection and disrupt the healing process.
D: Avoiding all physical activity for a month is incorrect as light activities are usually allowed, and complete inactivity can lead to complications like blood clots.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.