Nokea
A patient is ordered at 1400 to take Theophylline. You're assessing the patient's morning lab results and note that the Theophylline level drawn this morning reads: $15 \mathrm{mcg} / \mathrm{mL}$. You're next nursing action is to?
- A. Administer the dose at 1400 as ordered
- B. Notify the physician for further orders
- C. Hold the 1400 dose
- D. Collect another blood sample to confirm the level
Correct Answer: A
Rationale: A Theophylline level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the dose should be administered as ordered . No further action is needed.
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A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
- A. It produces greater blood oxygen levels.
- B. It is easier to breathe through the nose.
- C. The nares humidify, warm, and filter the air.
- D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Correct Answer: C
Rationale: The nares humidify, warm, and filter air, improving its quality for respiration.
Which statement by the client indicates an accurate understanding of the purpose of aerosol therapy?
- A. Aerosol therapy relieves tissue irritation.
- B. Aerosol therapy delivers medication directly to the lungs.
- C. Aerosolization dries respiratory passages.
- D. Aerosol therapy helps to slow breathing.
Correct Answer: B
Rationale: Aerosol therapy delivers medication directly to the lungs, targeting the respiratory tract for effective treatment of bronchitis.
When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.
The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering?
- A. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9.
- B. Multiple Choice insulin to a client with a blood glucose level of 218 mg/dL.
- C. Hang the heparin bag on a client with a PT/PTT of 12.9/98.
- D. A calcium channel blocker to the client with a BP of 112/82.
Correct Answer: C
Rationale: PTT 98 (C) is supratherapeutic for heparin, risking bleeding, so question administration. INR 1.9 (A) is subtherapeutic, insulin (B) is appropriate, and CCB (D) is reasonable.
Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?
- A. Visual stuffiness
- B. Dry cough
- C. High fever
- D. Scratchy throat
Correct Answer: C
Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.