Nokea
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
- A. Purpose of antibiotic therapy
- B. Ways to limit oral fluid intake
- C. Appropriate use of cough suppressants
- D. Safety concerns with home oxygen therapy
Correct Answer: C
Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.
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The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
- A. I have not had any acute asthma attacks during the last year.
- B. I became short of breath an hour before coming to the hospital.
- C. I've been taking Tylenol 650 mg every 6 hours for chest-wall pain.
- D. I've been using my albuterol inhaler more frequently over the last 4 days.
Correct Answer: D
Rationale: The correct answer is 'I've been using my albuterol inhaler more frequently over the last 4 days.' This statement indicates that the patient may need teaching regarding medication use because an increased need for a rapid-acting bronchodilator suggests an exacerbation of asthma. The patient should be educated on recognizing worsening symptoms and the appropriate actions to take. Choices A, B, and C do not directly relate to asthma exacerbation or the need for medication teaching, making them incorrect. Choice A reflects a lack of recent acute asthma attacks, while choice B describes shortness of breath unrelated to medication use. Choice C mentions Tylenol use for chest-wall pain, which is not indicative of asthma exacerbation or medication teaching needs.
A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
- A. Administer 2 ventilations
- B. Perform a head-tilt, chin lift to open the airway
- C. Begin chest compressions
- D. Perform a jaw thrust to open the airway
Correct Answer: C
Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should
- A. assess for the presence of chest pain.
- B. inquire about urinary tract problems.
- C. inspect the skin for rashes or discoloration.
- D. ask the patient about any increase in libido.
Correct Answer: B
Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
- A. Is there any family history of TB?
- B. How long have you lived in the United States?
- C. Do you take any over-the-counter (OTC) medications?
- D. Have you received the bacille Calmette-Guerin (BCG) vaccine for TB?
Correct Answer: D
Rationale: It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.