Nokea
The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Increased respiratory rate.
- B. Decreased oxygen saturation.
- C. Clear lung sounds.
- D. Elevated white blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.
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The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Serosanguineous drainage in the collection chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Chest tube secured to the client's chest wall.
Correct Answer: A
Rationale: The correct answer is A: Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber indicates an air leak in the system, which can lead to pneumothorax or compromised lung function. Immediate intervention is required to prevent complications. Serosanguineous drainage in the collection chamber (B) is expected after thoracotomy. Intermittent bubbling in the suction control chamber (C) is normal and indicates proper suction function. Chest tube secured to the client's chest wall (D) is essential for stability and should not require immediate intervention.
The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
- A. Hyperpigmentation of the skin.
- B. Hypotension.
- C. Moon face and buffalo hump.
- D. Weight loss.
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.
The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?
- A. Thickened and hardened skin.
- B. Painless ulcers on the fingertips.
- C. Episodes of cyanosis and pallor in the fingers.
- D. Red, scaly patches on the hands.
Correct Answer: C
Rationale: The correct answer is C: Episodes of cyanosis and pallor in the fingers. Raynaud's phenomenon is characterized by vasospasms of small arteries, leading to reduced blood flow and color changes in the digits. Cyanosis (bluish discoloration) and pallor (pale color) are common during episodes. Thickened and hardened skin (A) is associated with scleroderma. Painless ulcers on the fingertips (B) are seen in advanced stages of systemic sclerosis. Red, scaly patches on the hands (D) are indicative of psoriasis, not Raynaud's phenomenon.
A client is scheduled for a colonoscopy. Which instruction should the nurse provide?
- A. Eat a light breakfast on the day of the procedure.
- B. You will need to drink a bowel preparation solution before the procedure.
- C. Avoid all liquids for 24 hours before the procedure.
- D. You can continue taking your blood thinners until the day of the procedure.
Correct Answer: B
Rationale: The correct answer is B because drinking a bowel preparation solution helps clear the colon for better visualization during the colonoscopy. This step is crucial to ensure accuracy of the procedure. Choice A is incorrect as the client should have a clear liquid diet the day before the procedure. Choice C is incorrect as hydration is important, but clear liquids are allowed. Choice D is incorrect because blood thinners may need to be adjusted prior to the procedure to reduce bleeding risk.
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Hyperactivity
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Risperidone is an atypical antipsychotic medication known to cause metabolic side effects such as hyperglycemia. The nurse should monitor the client for signs and symptoms of high blood sugar levels, such as increased thirst, frequent urination, and fatigue. Hypertension (choice A) is not a common side effect of risperidone. Weight loss (choice B) is less likely as risperidone is associated with weight gain. Hyperactivity (choice C) is not a typical side effect of risperidone. Therefore, monitoring for hyperglycemia is essential in clients taking risperidone.