Nokea
A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect?
- A. Penicillin
- B. Fluroquinolones
- C. Tetracyclines
- D. Macrolides
Correct Answer: B
Rationale: Fluoroquinolones are associated with tendon rupture, including Achilles tendon, as a rare but serious side effect. Other antibiotics listed (A, C, D) are not commonly linked to this adverse effect.
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The physician orders the patient to start taking Omalizumab. How will you administer this medication as the nurse?
- A. Intravenous
- B. Intramuscular
- C. Orally
- D. Subcutaneously
Correct Answer: D
Rationale: Omalizumab is administered subcutaneously for asthma treatment.
Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?
- A. Alteration in comfort.
- B. Altered level of consciousness.
- C. Alteration in elimination pattern.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Pain (alteration in comfort, A) is a common issue post-thoracotomy due to surgical incision and chest tube placement, making it the most appropriate nursing diagnosis on day one. Altered consciousness (B) is not typical unless complications arise. Elimination issues (C) are less immediate. Knowledge deficit (D) is relevant later for discharge teaching.
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
- A. The client requests a consultation by the speech therapist.
- B. The client has a towel placed over the mirror.
- C. The client is attempting to shave himself.
- D. The client practices neck and shoulder exercises.
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.
The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.