Nokea
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
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The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
- A. Administer the ordered oral antibiotic immediately (STAT).
- B. Order the meal tray to be delivered as soon as possible.
- C. Obtain a sputum specimen for culture and sensitivity.
- D. Have the unlicensed assistive personnel weigh the client.
Correct Answer: C
Rationale: Obtaining sputum culture (C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (A) follow, meals (B) and weight (D) are less urgent.
If a client is allergic to penicillin, the nurse should anticipate a hypersensitivity response to which other group of antibiotics?
- A. Aminoglycosides such as kanamycin (Kantrex)
- B. Tetracyclines such as doxycycline (Vibramycin)
- C. Cephalosporins such as ceftriaxone (Rocephin)
- D. Fluoroquinolones such as ciprofloxacin (Cipro)
Correct Answer: C
Rationale: Cephalosporins have a similar beta-lactam structure to penicillin, increasing the risk of cross-reactivity in penicillin-allergic clients.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first?
- A. Notify the health-care provider to have chest tubes reinserted STAT.
- B. Instruct the client to take slow shallow breaths until the tube is reinserted.
- C. Take no action and assess the client's respiratory status every 15 minutes.
- D. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
Correct Answer: D
Rationale: An occlusive dressing taped on three sides (D) prevents air entry while allowing air exit, a priority. Notification (A), shallow breaths (B), and monitoring (C) follow.
Which nursing measure is most helpful in reducing the client's anxiety during an asthma attack?
- A. Close the door to the examination room.
- B. Remain within the client's view.
- C. Pull the bedside privacy curtain.
- D. Notify the client when the respiratory therapist arrives.
Correct Answer: B
Rationale: Remaining within the client's view provides reassurance and reduces anxiety by ensuring the client feels supported during an asthma attack.