Nokea
An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take?
- A. Assist the client to a high Fowler's position in bed
- B. Observe the client for the presence of a barrel chest
- C. Prepare to transfer the client to a critical care unit
- D. Instruct the client in pursed lip breathing techniques
Correct Answer: D
Rationale: Pursed lip breathing helps reduce dyspnea and improves oxygenation in clients with COPD.
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A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
A harsh, blowing grade IV/VI murmur is auscultated in a 6-month-old infant. What will the nurse practitioner do next?
- A. Get a complete blood count to rule out severe anemia.
- B. Obtain an electrocardiogram to assess for arrhythmia.
- C. Order a chest radiograph to evaluate for cardiomegaly.
- D. Refer to a pediatric cardiologist for further evaluation.
Correct Answer: D
Rationale: A harsh, blowing murmur is suspicious for pathology, so a cardiology referral is warranted.
The patient experiences a headache and is unable to move the left side of his body. The most likely cause is
- A. embolic stroke
- B. cerebral thrombosis
- C. cerebral abscess
- D. moyamoya disease
Correct Answer: A
Rationale: Embolic stroke is a common complication of cyanotic congenital heart disease.
Psychosis in children is suggested by:
- A. Absence of speech
- B. Intense outbursts of temper
- C. Recurrence of bed-wetting following a period of control
- D. Feelings of depersonalisation
Correct Answer: D
Rationale: Feelings of depersonalisation are a hallmark of psychosis. Absence of speech and temper outbursts are nonspecific, and bed-wetting is not diagnostic.
For the child with hypoplastic left heart syndrome, which medication may be given to keep the patent ductus arteriosus (PDA) open until surgery can be done?
- A. Prostaglandin E
- B. Indomethicin
- C. Ibuprofen
- D. Digoxin
Correct Answer: A
Rationale: Prostaglandin E is used to keep the PDA open in infants with hypoplastic left heart syndrome, allowing for adequate blood flow until surgical intervention can be performed.