Nokea
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?
- A. Pleuritic chest discomfort and anxiety.
- B. Asymmetrical chest expansion and pallor.
- C. Leukopenia and CRT <three (3) seconds.
- D. Substernal chest pain and diaphoresis.
Correct Answer: A
Rationale: Pneumonia causes pleuritic chest pain and anxiety (A) from inflammation/hypoxia. Asymmetry (B) suggests pneumothorax, leukopenia (C) is atypical, and substernal pain (D) suggests MI.
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The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.
The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
- A. Streptomycin
- B. Para-aminosalicylic (PAS) acid
- C. Isoniazid (INH)
- D. Ethambutol (Myambutol)
Correct Answer: C
Rationale: Isoniazid is the drug of choice for tuberculosis prophylaxis due to its effectiveness in preventing active disease.
The physician orders the patient to start taking Omalizumab. How will you administer this medication as the nurse?
- A. Intravenous
- B. Intramuscular
- C. Orally
- D. Subcutaneously
Correct Answer: D
Rationale: Omalizumab is administered subcutaneously for asthma treatment.
The nurse is preparing the client for a polysomnography to confirm sleep apnea. Which preprocedure instruction should the nurse include?
- A. The client should not eat or drink past midnight.
- B. The client will receive a sedative for relaxation.
- C. The client will sleep in a laboratory for evaluation.
- D. The client will wear a monitor at home for this test.
Correct Answer: C
Rationale: Polysomnography involves overnight monitoring in a sleep lab (C) to assess sleep patterns and confirm sleep apnea. Fasting (A) is unnecessary. Sedatives (B) are avoided to ensure natural sleep. Home monitors (D) are used for different tests, not polysomnography.
Which clinical manifestation would the nurse assess in the client newly diagnosed with intrinsic lung cancer?
- A. Dysphagia.
- B. Foul-smelling breath.
- C. Hoarseness.
- D. Weight loss.
Correct Answer: C
Rationale: Hoarseness (C) is a common early symptom of intrinsic lung cancer due to tumor compression of the recurrent laryngeal nerve. Dysphagia (A) is more typical of esophageal involvement. Foul-smelling breath (B) is non-specific. Weight loss (D) occurs later in advanced disease.