Nokea
After administering morphine sulfate (Roxanol) to the client, which of the following is most important for the nurse to assess?
- A. The rhythm of the heart
- B. Skin color and temperature
- C. Presence of bowel sounds
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Morphine can cause respiratory depression, so assessing the rate and depth of respirations is critical to ensure safety.
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Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
Which statement below is incorrect about a deep vein thrombosis (DVT)?
- A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral.
- B. DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too.
- C. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism.
- D. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein.
Correct Answer: C
Rationale: This option is INCORRECT. All the other statements are true about a DVT. Option C is wrong because it should say: 'A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.'
The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem 'altered communication.' Which intervention should the nurse implement?
- A. Instruct the client to drink a mixture of brandy and honey several times a day.
- B. Encourage the client to whisper instead of trying to speak at a normal level.
- C. Provide the client with a blank note pad for writing any communication.
- D. Explain that the client's aphonia may become a permanent condition.
Correct Answer: C
Rationale: A note pad (C) facilitates communication during laryngitis-related voice loss. Brandy/honey (A) is unproven, whispering (B) strains vocal cords, and permanent aphonia (D) is unlikely.
Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital?
- A. Avoid smoking and exposure to smoke.
- B. Do not receive flu or pneumonia vaccines.
- C. Avoid any type of alcohol intake.
- D. It will take about one (1) month to recuperate.
Correct Answer: A
Rationale: Avoiding smoke (A) prevents further lung damage, a priority post-ARDS. Vaccines (B) are recommended, alcohol (C) is not restricted, and recovery time (D) varies.
The best evidence that the client understands the procedure for a pulmonary function test is when stating that it involves which action?
- A. Having an X-ray taken
- B. Drawing a blood specimen
- C. Breathing into a mouthpiece
- D. Examining expectorated sputum
Correct Answer: C
Rationale: Pulmonary function tests involve breathing into a mouthpiece to measure lung capacity and airflow.