Nokea
An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?
- A. Administer a prescribed sedative
- B. Encourage client to drink water
- C. Apply a high-flow venturi mask
- D. Assist her to an upright position
Correct Answer: D
Rationale: An upright position improves lung expansion and oxygenation, which is crucial for a client with COPD.
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During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. An old friend with eczema came for a visit
- B. Recently received an influenza immunization
- C. A grandson and his new dog recently visited
- D. Corticosteroid cream was applied to eczema
Correct Answer: C
Rationale: Exposure to new allergens, such as a pet, can trigger eczema flare-ups.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?
- A. The foster mother
- B. The social worker who placed the infant in the foster home
- C. The registered nurse caring for the infant
- D. The nurse-manager
Correct Answer: A
Rationale: The foster mother, as the primary caregiver, is typically authorized to provide consent for medical procedures.
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
- A. Re-orient the client to his present location and circumstances
- B. Confirm that this is an effective technique to help with ambulation
- C. Assist the client to a carpeted area where he can walk more easily
- D. Plan to assess the client's cognition after returning to his room
Correct Answer: B
Rationale: Pretending to step over a crack is a known technique that can help clients with PD overcome freezing episodes.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
- A. Administration of IV furosemide (Lasix)
- B. Initiation of an external pacemaker
- C. Assistance with endotracheal intubation
- D. Placement of central venous access
Correct Answer: B
Rationale: An 80% blockage of the RCA can lead to bradycardia or heart block. An external pacemaker may be needed to maintain adequate heart rate and cardiac output.