Nokea
The client experiencing a severe allergic reaction becomes pulseless. The nurse shakes the client, shouts the client's name, and activates the emergency medical response system. Which nursing action becomes the next priority?
- A. Administer a single blow to the sternum.
- B. Give two quick breaths that make the chest visibly rise.
- C. Begin chest compressions at a rate of 100 per minute.
- D. Administer an epinephrine (Adrenalin) injection.
Correct Answer: C
Rationale: For a pulseless client, starting chest compressions immediately after activating the emergency response is the priority to restore circulation, per CPR guidelines.
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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 observation best indicates that a client with a pneumothorax is developing a tension pneumothorax?
- A. The trachea is deviated.
- B. The client is coughing.
- C. The chest is asymmetrical.
- D. The client reports sharp pain.
Correct Answer: A
Rationale: Tracheal deviation is a hallmark sign of tension pneumothorax, indicating mediastinal shift due to increased intrathoracic pressure.
A patient with severe COPD is having an episode of extreme shortness of breath and requests their inhaler. Which type of inhaler ordered by the physician would provide the FASTEST relief for the patient based on this particular situation?
- A. Spiriva
- B. Salmeterol
- C. Symbicort
- D. Albuterol
Correct Answer: D
Rationale: Albuterol , a short-acting beta-agonist, provides rapid bronchodilation for acute shortness of breath. Spiriva , Salmeterol , and Symbicort are long-acting or combination drugs for maintenance.
Which household measurement should the nurse use when teaching the client how to self-administer the prescribed amount of liquid cough syrup?
- A. One ounce
- B. One tablespoon
- C. One teaspoon
- D. One capful
Correct Answer: C
Rationale: A 5 mL dose of liquid cough syrup is equivalent to one teaspoon, a standard household measurement.
The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client?
- A. Increase fluid intake to two (2) to three (3) L/day.
- B. Eat a low-cholesterol, low-fat diet.
- C. Avoid being around large crowds.
- D. Receive pneumonia and flu vaccines.
Correct Answer: A
Rationale: Increased fluids (A) prevent dehydration, reducing clotting risk in PE. Low-fat diet (B), avoiding crowds (C), and vaccines (D) are less specific.