Nokea
The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client?
- A. Have you had the flu shot in the last two (2) weeks?
- B. Are there any small children in the home?
- C. Are you taking over-the-counter medicine for these symptoms?
- D. Do you have any cold sores associated with your sneezing?
Correct Answer: C
Rationale: Sneezing and nasal discharge suggest a URI; asking about OTC medications (C) assesses self-treatment and potential interactions. Flu shot timing (A) is irrelevant, children (B) are secondary, and cold sores (D) relate to herpes, not URI.
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Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.
A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis?
- A. He drinks raw milk.
- B. He cleans chicken houses.
- C. He handles fertilizer frequently.
- D. He stepped on a rusty nail recently.
Correct Answer: B
Rationale: Cleaning chicken houses exposes the client to bird droppings, a common source of Histoplasma capsulatum, the fungus causing histoplasmosis.
The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time?
- A. Stimulate the client until the client responds.
- B. Increase the oxygen from the ordered 6 L to 10 L.
- C. Assess the client again in 15 minutes.
- D. Notify the charge nurse of the change in the client's mental status.
Correct Answer: D
Rationale: A change in mental status with worsening dyspnea indicates potential deterioration, requiring immediate notification of the charge nurse.
A client who had a laryngectomy is nearly ready for discharge. Which instruction is most appropriate for the nurse to give?
- A. Always be sure you have a buddy with you when you go swimming or boating.'
- B. You may take a tub bath, but you should not take a shower.'
- C. Be sure to have only liquids for another three weeks.'
- D. Never cover your stoma with anything.'
Correct Answer: A
Rationale: A buddy is essential during swimming or boating to ensure safety, as water entering the stoma can cause aspiration.
Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM?
- A. pH 7.38, Pao2 94, Paco2 44, Hco3 24.
- B. pH 7.46, Pao2 82, Paco2 34, Hco3 22.
- C. pH 7.48, Pao2 59, Paco2 30, Hco3 26.
- D. pH 7.33, Pao2 94, Paco2 44, Hco3 20.
Correct Answer: C
Rationale: ARDS is characterized by severe hypoxemia despite high oxygen delivery. Pao2 59 (C) despite 10 LPM oxygen indicates refractory hypoxia, a hallmark of ARDS. Normal Pao2 (94 in A and D) contradicts ARDS. Pao2 82 (B) is low but not as severe as 59, making C the best indicator of ARDS.