Nokea
The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.
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The nurse is caring for a client who is admitted with histoplasmosis. What drug is most likely to be prescribed for this client?
- A. Penicillin
- B. Chloromycetin
- C. Streptomycin
- D. Amphotericin B
Correct Answer: D
Rationale: Amphotericin B is the primary antifungal drug used to treat histoplasmosis.
You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing?
- A. Peak flow meter; pneumonia
- B. Incentive spirometer; thrush
- C. Spacer; thrush
- D. Peak flow meter; mouth sores
Correct Answer: C
Rationale: A spacer helps deliver Budesonide, an inhaled corticosteroid, more effectively to the lungs, reducing the risk of oral thrush by minimizing medication deposition in the mouth.
When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.
The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?
- A. Standard Precautions.
- B. Contact Precautions.
- C. Droplet Precautions.
- D. Airborne Precautions.
Correct Answer: D
Rationale: TB is transmitted via airborne droplets, requiring airborne precautions (D) with negative-pressure rooms. Standard (A), contact (B), and droplet (C) are insufficient.
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.