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A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings would indicate that the treatment has been effective? Which finding indicates effective cool mist tent treatment?
- A. Decreased stridor
- B. Decreased temperature
- C. Barking cough
- D. Improved hydration
Correct Answer: A
Rationale: The correct answer is A: Decreased stridor. Stridor is a high-pitched sound produced by turbulent airflow in the upper airway, which indicates airway obstruction. In acute laryngotracheobronchitis, the airway is inflamed and narrowed, leading to stridor. Placing the toddler in a cool mist tent helps reduce airway inflammation and swelling, leading to improved airflow and decreased stridor. Therefore, a decrease in stridor would indicate that the treatment has been effective.
Summary of Incorrect Choices:
B: Decreased temperature - This choice does not directly relate to the effectiveness of the cool mist tent treatment for laryngotracheobronchitis.
C: Barking cough - Barking cough is a characteristic symptom of croup, which is present in acute laryngotracheobronchitis. It does not specifically indicate the effectiveness of the cool mist tent treatment.
D: Improved hydration - While hydration is important in managing respiratory conditions
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A nurse is caring for a patient who has a history of heart failure and is receiving furosemide. Which of the following laboratory results should the nurse monitor? Which lab result should the nurse monitor for furosemide?
- A. Serum potassium
- B. Serum calcium
- C. Serum magnesium
- D. Serum sodium
Correct Answer: A
Rationale: The correct answer is A: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. Monitoring serum potassium levels is crucial to prevent hypokalemia, which can lead to cardiac arrhythmias in a patient with a history of heart failure. Serum calcium (B) and magnesium (C) are not directly affected by furosemide use. Serum sodium (D) monitoring is important for other conditions but not specific to furosemide therapy in this case.
A nurse is caring for a patient whose right leg is in Buck's traction. Which interventions should the nurse implement to promote the patient's mobility? Which intervention promotes mobility in Buck's traction?
- A. Perform passive range of motion exercises on the right leg.
- B. Perform isometric exercises on both legs.
- C. Perform active range-of-motion exercises on the left leg.
- D. Log roll the patient every 2 hours.
Correct Answer: C
Rationale: Rationale: Performing active range-of-motion exercises on the left leg promotes mobility in Buck's traction by maintaining muscle strength and joint flexibility, preventing muscle atrophy, and improving circulation. This helps prevent complications and supports eventual rehabilitation. Passive range of motion exercises on the right leg are not recommended as it may cause discomfort. Isometric exercises on both legs may not address the specific immobilization of the right leg. Log rolling every 2 hours is not directly related to promoting mobility in Buck's traction.
A nurse is conducting a patient's history and physical examination. Which information should the nurse consider as subjective data? Which information is subjective data?
- A. Petechiae
- B. Nausea
- C. Cyanosis
- D. Fever
Correct Answer: B
Rationale: Subjective data is information provided by the patient based on their feelings, perceptions, or beliefs. Nausea falls under this category as it is a symptom that the patient experiences and reports subjectively. Petechiae, cyanosis, and fever are objective data as they can be observed or measured directly. Petechiae are small red or purple spots on the skin, cyanosis is a bluish discoloration of the skin due to lack of oxygen, and fever is an elevated body temperature, all of which can be confirmed through visual inspection or measurement. Therefore, choice B, nausea, is the correct answer as it relies on the patient's subjective experience.
A nurse is administering an oral medication to an older adult patient. The patient states, 'The pill I always take is green. I don't take an orange pill.' What should the nurse respond? What should the nurse respond to a pill color concern?
- A. This is the medication that your doctor wants you to take.
- B. Sometimes the same pill comes in a different color.
- C. I will check your medication order again.
- D. Let me explain the purpose of the medication.
Correct Answer: C
Rationale: The correct answer is C: I will check your medication order again. The nurse should respond this way because the patient is confused about the color of the pill, indicating a potential medication error. By checking the medication order again, the nurse can ensure that the patient receives the correct medication. Choice A does not address the patient's concern about the pill color. Choice B may confuse the patient further and does not address the potential error. Choice D is not relevant to the patient's immediate concern about the pill color.
A nurse is instructing a patient who has been newly prescribed sumatriptan tablets for the treatment of migraine headaches. Which instructions should the nurse include? What instructions should the nurse include for sumatriptan?
- A. Report any eyelid swelling after dosage.
- B. Repeat the dose in 1 hour if the headache persists.
- C. Take the medication daily to prevent headaches.
- D. Thoroughly chew the tablet before swallowing.
Correct Answer: B
Rationale: The correct answer is B: Repeat the dose in 1 hour if the headache persists. Sumatriptan is used to treat acute migraine attacks, and the patient should be instructed to take a second dose if the headache does not improve after the first dose. This is important because it helps ensure adequate relief of symptoms. Choices A and D are incorrect because eyelid swelling is not a common side effect of sumatriptan, and sumatriptan tablets should be swallowed whole without chewing. Choice C is incorrect because sumatriptan is not taken daily for headache prevention; it is used as needed for acute migraine attacks.