Nokea
A student nurse overhears her instructor using the term pink puffer. The student knows this term refers to a client with which condition?
- A. chronic bronchitis
- B. chronic obstructive pulmonary disease (COPD)
- C. emphysema
- D. allergic asthma
Correct Answer: C
Rationale: Pink puffer' describes emphysema patients, who maintain oxygenation (pink) but hyperventilate (puffer) due to alveolar destruction.
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Two Mexican immigrant families live closely together and share goods, services, and childcare. To which of the following family structures does this model correspond?
- A. Kinship network
- B. Binuclear
- C. Nuclear
- D. Extended
Correct Answer: A
Rationale: A kinship network (A) involves close family units sharing resources, typical in some Mexican cultures. Extended (D) is broader, nuclear (C) is single-family, and binuclear (B) involves divorce.
When examining an 80-year-old client with chronic COPD receiving home health care, the nurse notes that over the previous 48 hours the client has developed scattered painful pustular lesions on the right arm near the elbow (see photo), on the back of the neck, the face, and on both legs. Which of the following does the nurse suspect is the most likely cause of the lesions?
- A. Psoriasis
- B. Herpes zoster
- C. MRSA
- D. Contact dermatitis
Correct Answer: C
Rationale: Painful pustular lesions in a client with chronic illness suggest MRSA (C), a common healthcare-associated infection. Psoriasis (A) presents with scaly plaques, herpes zoster (B) follows a dermatomal pattern, and contact dermatitis (D) is typically itchy, not pustular.
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about his pain.
- B. What does his vomit look like?
- C. Describe his usual diet.
- D. Have you noticed changes in his abdominal size?
Correct Answer: C
Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A. Place the client in a sitting position.
- B. Administer acetaminophen (Tylenol).
- C. Pinch the soft lower part of the nose.
- D. Apply ice packs to the forehead.
Correct Answer: C
Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the heparin drip rate
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of vascular assessments
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.