Nokea
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
- A. Administering bronchodilators as prescribed.
- B. Encouraging the patient to avoid physical activity.
- C. Providing supplemental oxygen as needed.
- D. Monitoring for signs of acute kidney injury.
Correct Answer: A
Rationale: The correct answer is A: Administering bronchodilators as prescribed.
Rationale:
1. Bronchodilators help dilate the airways, improving airflow in COPD patients.
2. Priority is to address the underlying respiratory issue.
3. Bronchodilators are a standard treatment for managing COPD symptoms.
4. Improving airway patency is crucial in COPD exacerbations.
Summary:
- B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning.
- C: Providing supplemental oxygen is important but not the priority in this case.
- D: Monitoring for acute kidney injury is unrelated to COPD management.
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What is the priority nursing intervention for a client with a history of asthma experiencing wheezing?
- A. Administer oxygen
- B. Apply a bronchodilator
- C. Apply a cold compress
- D. Encourage deep breathing
Correct Answer: A
Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.
What is the first step in the care of a client with a severe allergic reaction?
- A. Administer epinephrine
- B. Administer corticosteroids
- C. Administer corticosteroids
- D. Apply a cold compress
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.
What is the priority action for a client who presents with symptoms of stroke?
- A. Perform a CT scan
- B. Monitor blood pressure
- C. Administer aspirin
- D. Administer thrombolytics
Correct Answer: A
Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride
- B. potassium and phosphate
- C. sodium and chloride
- D. sodium and phosphate
Correct Answer: C
Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.
Which technique should the nurse use to determine the presence of crepitus during a physical examination?
- A. Percussion
- B. Auscultation
- C. Palpation
- D. Auscultation
Correct Answer: A
Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.