Nokea
Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.
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The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client?
- A. Have you had the flu shot in the last two (2) weeks?
- B. Are there any small children in the home?
- C. Are you taking over-the-counter medicine for these symptoms?
- D. Do you have any cold sores associated with your sneezing?
Correct Answer: C
Rationale: Sneezing and nasal discharge suggest a URI; asking about OTC medications (C) assesses self-treatment and potential interactions. Flu shot timing (A) is irrelevant, children (B) are secondary, and cold sores (D) relate to herpes, not URI.
The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription?
- A. These pills will make me feel better fast and I can return to work.
- B. The antibiotics will help prevent me from developing a bacterial pneumonia.
- C. If I had gotten this prescription sooner, I could have prevented this illness.
- D. I need to take these pills until I feel better; then I can stop taking the rest.
Correct Answer: B
Rationale: Antibiotics for influenza (B) prevent secondary bacterial pneumonia, not treat the virus. Quick recovery (A), prevention (C), and stopping early (D) are incorrect.
The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching?
- A. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise.
- B. Warm-up exercises will increase the potential for developing the asthma attacks.
- C. Use the bronchodilator inhaler immediately prior to beginning to exercise.
- D. Increase dietary intake of food high in monosodium glutamate (MSG).
Correct Answer: A
Rationale: Two puffs of a rescue inhaler 5 minutes before exercise (A) prevents EIA. Warm-ups (B) reduce attacks, immediate use (C) is less effective, and MSG (D) is a trigger.
Which action is most appropriate for the nurse to take before the bronchoscopy?
- A. Keep the client NPO for at least 6 hours.
- B. Have the client cough several times.
- C. Ensure that the client gets adequate sleep.
- D. Scrub the client's upper chest with an antiseptic.
Correct Answer: A
Rationale: Keeping the client NPO for at least 6 hours prevents aspiration during bronchoscopy, which involves sedation.
A patient received a nebulizer of Albuterol. What is a side effect of this medication?
- A. Bradycardia
- B. Tachycardia
- C. Drowsiness
- D. Feeling cold
Correct Answer: B
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to its stimulatory effects.