Nokea
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
- A. Mechanical ventilation
- B. Nebulizer treatments
- C. Chest physiotherapy
- D. Antibiotic therapy
Correct Answer: A
Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.
You may also like to solve these questions
The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?
- A. Exploratory laparotomy with a colon resection the previous shift
- B. Client with a stroke who has been hospitalized for two days
- C. A client with metastatic cancer on PCA morphine
- D. A new admission with diverticulitis
Correct Answer: B
Rationale: A stable stroke client (hospitalized for two days) is appropriate for a nursing assistant, who can assist with basic care (e.g., hygiene, mobility). Recent surgery (A), PCA morphine (C), and new admissions (D) require higher-level nursing skills.
The nurse is caring for a client with a history of myasthenia gravis. The nurse should assess the client for:
- A. Muscle weakness
- B. Joint stiffness
- C. Skin lesions
- D. Chest pain
Correct Answer: A
Rationale: Myasthenia gravis causes autoimmune destruction of acetylcholine receptors, leading to muscle weakness, especially in the eyes, face, and limbs, a key assessment finding.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:
- A. 12-15 months of age
- B. 18-24 months of age
- C. 26-30 months of age
- D. 32-36 months of age
Correct Answer: B
Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.
An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.