Nokea
Steve, who is diagnosed with pneumonia following recent intrathoracic surgery, will likely be prescribed
- A. Cephalosporin, such as cefazolin.
- B. Penicillin, such as amoxicillin.
- C. Fluoroquinolone, such as levofloxacin.
- D. Tetracycline, such as doxycycline.
Correct Answer: A
Rationale: Cephalosporins are commonly used antibiotics for treating post-surgical pneumonia.
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What statement indicates Mr. Singer understands his condition after viewing a filmstrip on rehabilitation?
- A. ‘I will be able to continue my swimming as usual.’
- B. ‘I will regain some degree of my sense of smell and taste.’
- C. ‘I will not be able to bowl any more.’
- D. ‘I will have to give up my tub bath.’
Correct Answer: B
Rationale: Partial recovery of senses is possible after laryngectomy.
List the order in which you will assess these patients.
- A. An ambulatory, dazed 25-year-old male with a bandaged head wound
- B. An irritable infant with a fever, petechiae, and nuchal rigidity
- C. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
- D. A 50-year-old female with moderate abdominal pain and occasional vomiting
Correct Answer: B
Rationale: The infant with fever, petechiae, and nuchal rigidity may indicate meningitis, a life-threatening condition requiring immediate attention.
What would be the best response by the nurse to a quiet and uncommunicative client?
- A. Think over the following questions.
- B. Discuss them with your instructor or peers.
- C. Acknowledge their feelings and encourage expression.
- D. Offer silence and wait patiently.
Correct Answer: D
Rationale: Silence can provide the client with space to open up when they feel ready, fostering trust and rapport.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.
A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.