Nokea
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.
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Which is the correct volume needed for the nurse to administer the prescribed dose of 0.1 mg of epinephrine to the client?
- A. 0.001 mL
- B. 0.1 mL
- C. 1.0 mL
- D. 10 mL
Correct Answer: B
Rationale: For a 1:1,000 epinephrine solution (1 mg/mL), a 0.1 mg dose equals 0.1 mL, calculated as 0.1 mg ÷ 1 mg/mL = 0.1 mL.
The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply.
- A. Nursing.
- B. Pharmacy.
- C. Social work.
- D. Occupational therapy.
- E. Speech therapy.
Correct Answer: A,B,C
Rationale: Nursing (A), pharmacy (B), and social work (C) address asthma management, medications, and social needs. Occupational (D) and speech (E) therapies are less relevant.
Before discharging a client with fractured ribs from the emergency department, which instruction is most important for the nurse to give the client?
- A. Avoid coughing to prevent further injury.
- B. Take deep breaths periodically.
- C. Apply heat to the chest daily.
- D. Sleep in a prone position.
Correct Answer: B
Rationale: Taking deep breaths periodically prevents atelectasis and pneumonia, which are risks with fractured ribs due to shallow breathing.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, 'What is happening to me? Why did I get this?' Which statement by the nurse is most appropriate?
- A. Most people who almost drown end up developing ARDS.
- B. Platelets and fluid enter the alveoli due to permeability instability.
- C. Your lungs are filling up with fluid, causing breathing problems.
- D. Smoking has caused your lungs to become weakened, so you got ARDS.
Correct Answer: C
Rationale: Fluid-filled lungs (C) explain ARDS simply, addressing breathing issues. Drowning link (A), permeability (B), and smoking (D) are less accurate or overly technical.
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.