Nokea
The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
You may also like to solve these questions
The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple ecchymotic areas on the arms. Based on the assessment data, which question should the nurse ask the client?
- A. Do you take prednisone?
- B. Can you tell me who hurts you?
- C. May I check your coccyx for pressure areas?
- D. Do you sleep with the head of the bed elevated?
Correct Answer: A
Rationale: Thin limbs, truncal obesity, and ecchymosis (A) suggest corticosteroid use (e.g., prednisone) in COPD. Abuse (B), pressure ulcers (C), and HOB elevation (D) are less likely.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.
When the nurse is teaching a client to self-administer nose drops, which head position is appropriate?
- A. Bending the head forward, then instilling the drops
- B. Pushing the nose laterally, then instilling the drops
- C. Tilting the head backward, then instilling the drops
- D. Turning the head to the side, then instilling the drops
Correct Answer: C
Rationale: Tilting the head backward allows nose drops to reach the nasal passages effectively by gravity, ensuring proper distribution of the medication.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?
- A. The client's partial thromboplastin time (PTT) is 38.
- B. The client's international normalized ratio (INR) is 5.
- C. The client's prothrombin time (PT) is 22.
- D. The client's erythrocyte sedimentation rate (ESR) is 10.
Correct Answer: B
Rationale: An INR of 5 (B) is above the therapeutic range (2–3 for pulmonary embolus), indicating excessive anticoagulation and bleeding risk, so warfarin should be questioned. PTT (A) is for heparin, not warfarin. PT (C) alone is not standardized. ESR (D) is irrelevant to anticoagulation.
When the client asks the nurse why skin testing is beneficial, which explanation is best?
- A. The symptoms may be related to more than one substance.
- B. Skin testing helps to build up blocking antibodies.
- C. Allergic responses vary from person to person.
- D. The allergy symptoms could become more serious.
Correct Answer: A
Rationale: Skin testing identifies specific allergens causing symptoms, which is crucial when symptoms may be triggered by multiple substances.