Nokea
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents these findings as:
- A. Tachypnea
- B. Hyperpyrexia
- C. Arrhythmia
- D. Tachycardia
Correct Answer: D
Rationale: Tachycardia is an elevated heart rate; tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is irregular rhythm.
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Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
- A. Bend at the waist and place arms under the client's arms and lift
- B. Face the client, bend knees and place hands on client's forearm and lift
- C. Spread his or her feet apart
- D. Tighten his or her pelvic muscles
Correct Answer: B
Rationale: Facing the client, bending knees, and using forearms provides a wide base and proper body mechanics for safe lifting.
One tablet of chlorine is efficient to chlorinate how many litres of water?
- A. 10 Litres
- B. 20 Litres
- C. 30 Litres
- D. 40 Litres
Correct Answer: B
Rationale: Chlorine tablets disinfect water by releasing hypochlorous acid to kill pathogens. Standard tablets (e.g., 1 mg chlorine) are designed to treat specific volumes based on concentration needs (typically 0.5-2 mg/L). Choice A (10 L) underestimates common tablet capacity, while C (30 L) and D (40 L) exceed typical single-tablet efficacy without specifying tablet strength. B (20 L) aligns with widely used chlorine tablets (e.g., NaDCC) for household water purification, achieving safe levels per WHO guidelines. Nurses educating communities on water safety must clarify dosage, ensuring effective pathogen control without overdose, making 20 L the correct, practical answer.
Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: Mashed potatoes and broiled chicken are low in sodium, unlike ham, olives, or bouillon.