Nokea
The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate?
- A. Pneumovax protects you for your lifetime.
- B. Immunity afforded you by Pneumovax lasts only 2 years.
- C. Pneumovax protection varies according to your risk factors and living situation.
- D. After 6 years, you need a repeat dose of Pneumovax for full immunity.
Correct Answer: D
Rationale: Step 1: Pneumovax is recommended for adults aged 65 and older.
Step 2: Immunity from Pneumovax decreases over time.
Step 3: CDC recommends a second dose of Pneumovax after 5 years for those at highest risk.
Step 4: Answer D is correct as it aligns with CDC guidelines for revaccination.
Step 5: Other choices are incorrect as they do not reflect current recommendations or scientific evidence.
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A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain?
- A. Average daily fluid intake.
- B. Neck circumference.
- C. Height and weight.
- D. Occupation and hobbies.
Correct Answer: D
Rationale: The correct answer is D: Occupation and hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, leading to potential respiratory issues. By assessing their occupation and hobbies, the nurse can identify any risks or triggers that could impact the client's respiratory status.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference may be relevant for assessing airway obstruction risk but is not as critical as occupation and hobbies.
C: Height and weight are more related to general health and body mass index, not specifically respiratory status assessment.
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
- A. Immediately after a meal
- B. First thing in the morning
- C. At bedtime
- D. After a period of exercise
Correct Answer: B
Rationale: The correct answer is B: First thing in the morning. Sputum should be collected in the morning because it is usually more concentrated, making it easier to obtain a good sample. This is important for accurate analysis and identifying potential pathogens causing the patient's symptoms. Collecting sputum immediately after a meal may result in contamination with food particles. At bedtime, sputum may have accumulated overnight, but morning samples are still preferred due to concentration. Collecting sputum after a period of exercise may introduce respiratory secretions not reflective of the underlying condition.
Hypoxia
- A. causes hyperventilation
- B. may cause headaches, nausea, and lethargy.
- C. can lead to loss of consciousness and death
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D because hypoxia, which is a condition of low oxygen levels in the body, can indeed lead to hyperventilation, as the body tries to compensate. It can also cause symptoms like headaches, nausea, and lethargy due to the lack of oxygen reaching the brain and other organs. Severe hypoxia can lead to loss of consciousness and even death if oxygen levels are not restored promptly. Therefore, all the statements in choices A, B, and C are true in relation to hypoxia, making option D the correct choice.
A 17-year-old male is admitted following an automobile accident. He is very anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of?
- A. Hemothorax
- B. Flail chest
- C. Atelectasis
- D. Pleural effusion
Correct Answer: B
Rationale: The correct answer is B: Flail chest. Flail chest is characterized by paradoxical movement of a segment of the chest wall due to multiple rib fractures. In this case, the left chest wall moving in during inspiration and out during expiration indicates this paradoxical movement. This leads to ineffective breathing, causing dyspnea and anxiety. Hemothorax (A) is accumulation of blood in the pleural cavity, not associated with chest wall movement. Atelectasis (C) is collapse of lung tissue, not associated with chest wall movement. Pleural effusion (D) is accumulation of fluid in the pleural space, also not associated with paradoxical chest wall movement.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To help the client drink fluids
- C. To prevent respiratory obstruction
- D. To prevent excessive bleeding
Correct Answer: A
Rationale: The correct answer is A. An ice collar reduces swelling and pain by constricting blood vessels and numbing the area. B (helping the client drink fluids) is unrelated. C (preventing respiratory obstruction) is not the primary purpose of an ice collar. D (preventing excessive bleeding) is managed differently, usually with direct pressure or medication.