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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The pH of urine:
- A. Is a useful indicator of the acid/base balance of blood
- B. Rises on a vegetarian diet
- C. Is determined by the concentration of ammonium
- D. Is lower than 5.5 in renal tubular acidosis
Correct Answer: A
Rationale: Urine pH reflects blood acid/base balance. A vegetarian diet typically raises urine pH, and renal tubular acidosis causes a higher pH, not lower.
Which is/are true?
- A. Babies are able to respond to sounds in utero
- B. Full term babies at birth are unable to follow a large object with their eyes
- C. A 6-week-old infant would be able to follow a large object through an arc of 135°
- D. Growth velocity of head decreases with age
Correct Answer: A
Rationale: Babies can respond to sounds in utero, and head growth velocity does decrease with age. Full-term babies can follow large objects, and a 6-week-old can follow objects through a smaller arc.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should take priority?
- A. Prevent accidents
- B. Keeping a night light on to allay fears
- C. Explaining normalcy of fears about body integrity
- D. Encouraging the child to dress without help
Correct Answer: A
Rationale: Accident prevention is a priority for school-age children as they become more independent and engage in activities that may pose risks.
Diseases that primarily involve the motor unit include:
- A. Werdnig-Hoffman disease
- B. Guillain-Barre syndrome
- C. Facioscapulohumeral dystrophy
- D. Charcot-Marie-Tooth disease
Correct Answer: A
Rationale: Werdnig-Hoffman disease, also known as spinal muscular atrophy type 1, primarily affects the motor neurons in the spinal cord.