Nokea
The charge nurse is making rounds. Which client should the nurse assess first?
- A. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude.
- B. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities.
- C. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL.
- D. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.
Correct Answer: C
Rationale: Blood glucose 189 mg/dL in DKA (C) indicates potential instability, requiring immediate assessment. Rudeness (A), edema (B), and stable COPD (D) are less urgent.
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When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
Which nursing observation provides the best evidence that postural drainage is effective?
- A. The client's respiratory rate is increased.
- B. The client's heart rate is much improved.
- C. The client's sputum culture is negative.
- D. The client raises a large volume of sputum.
Correct Answer: D
Rationale: Raising a large volume of sputum indicates that postural drainage is effectively clearing secretions from the airways.
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
- A. The most difficult time of the day for me is the first hour after waking up in the morning.'
- B. I feel best in the morning after a good night's sleep.'
- C. I seem to have more energy after eating a big meal.'
- D. I don't know why, but I get my 'second wind' at night and don't want to go to bed.'
Correct Answer: A
Rationale: Morning fatigue is common in COPD due to mucus accumulation and poor sleep, affecting activity tolerance.