Nokea
Joan is at lunch in the hospital cafeteria with a nurse coworker. Joan is very allergic to nuts and always carries her anaphylactic kit with her. Joan tells her coworker that there must have been nuts in something she ate because she is having increasing difficulty breathing. What should the nurse do immediately?
- A. Take her to the hospital emergency room
- B. Administer the medication in her friend's anaphylactic kit
- C. Call the floor for help
- D. Monitor the symptoms
Correct Answer: B
Rationale: Administering the anaphylactic kit medication (epinephrine) is the immediate action to reverse anaphylaxis, prioritizing airway patency.
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The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?
- A. I go to the bathroom a lot more than usual
- B. It burns when I pee.
- C. My urine is cloudy
- D. There is a red rash on my abdomen.
Correct Answer: D
Rationale: A rash may indicate an allergic reaction, requiring urgent follow-up. Frequent urination , burning , and cloudy urine are UTI symptoms.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?
- A. He bends over to tie his shoes.
- B. He tells the nurse he takes a lot of pills every day.
- C. He ambulates daily.
- D. He tells the nurse he has ordered a medical identification bracelet.
Correct Answer: A
Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.