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The client is admitted with a diagnosis of rule-out severe acute respiratory syndrome (SARS). Which information is most important for the nurse to ask related to this diagnosis?
- A. Current prescription and over-the-counter medication use.
- B. Dates of and any complications associated with recent immunizations.
- C. Any problems with recent or past use of blood or blood products.
- D. Recent travel to mainland China, Hong Kong, or Taiwan.
Correct Answer: D
Rationale: SARS is associated with outbreaks in specific regions, notably China, Hong Kong, and Taiwan. Recent travel to these areas (D) is critical for assessing exposure risk. Medications (A), immunizations (B), and blood products (C) are less relevant to SARS diagnosis, which relies on travel history and symptoms.
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The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- A. The UAP keeps the chest tube below chest level.
- B. The UAP has the chest tube attached to suction.
- C. The UAP allowed the client out of the bed.
- D. The UAP uses a bedside commode for the client.
Correct Answer: B
Rationale: Suction during ambulation (B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (A), ambulation (C), and commode (D) are appropriate.
The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
- A. The client diagnosed with congestive heart failure.
- B. The client with a documented allergy to eggs.
- C. The client who has had an anaphylactic reaction to penicillin.
- D. The client who has an elevated blood pressure and pulse.
Correct Answer: B
Rationale: Influenza vaccines are often grown in eggs, making egg allergy (B) a contraindication due to anaphylaxis risk. Congestive heart failure (A), penicillin allergy (C), and elevated vitals (D) are not contraindications for the flu vaccine.
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply.
- A. Impaired gas exchange.
- B. Inability to tolerate temperature extremes.
- C. Activity intolerance.
- D. Inability to cope with changes in roles.
- E. Alteration in nutrition.
Correct Answer: A,C,D,E
Rationale: COPD causes impaired gas exchange (A), activity intolerance (C), role changes (D), and nutritional issues (E) from energy demands. Temperature intolerance (B) is not primary.
The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first?
- A. Request STAT arterial blood gases.
- B. Administer lidocaine intravenous push.
- C. Assess for possible causes.
- D. Request a STAT electrocardiogram.
Correct Answer: C
Rationale: Frequent PVCs post-thoracotomy may stem from hypoxia, electrolyte imbalances, or pain. Assessing for causes (C) is the first step to identify and address the underlying issue. ABGs (A) or ECG (D) may follow based on findings. Lidocaine (B) is premature without identifying the cause.
Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma in clients diagnosed with chronic obstructive pulmonary disease (COPD)?
- A. A bronchoscopy.
- B. An immunoglobulin E.
- C. An arterial blood gas.
- D. A bronchodilator reversibility test.
Correct Answer: D
Rationale: A bronchodilator reversibility test differentiates asthma from COPD by assessing whether airway obstruction is reversible. In asthma, lung function (e.g., FEV1) improves significantly post-bronchodilator, while COPD shows minimal improvement. Bronchoscopy (A) is invasive and not specific for this differentiation. Immunoglobulin E (B) is relevant for allergies, not distinguishing asthma from COPD. Arterial blood gases (C) assess oxygenation but do not differentiate these conditions.