Nokea
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following statements?
- A. My son plays the tuba in the grade school band.
- B. My son loves to help his dad rake leaves.
- C. My son participates in after-school activities three days a week.
- D. My son walks one mile to school every day with his friends.
Correct Answer: B
Rationale: main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves
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The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- A. Change the nursing assistant's assignment
- B. Explore the interaction with the nursing assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the nursing assistant
Correct Answer: B
Rationale: Exploring the interaction addresses the behavior appropriately.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- A. Have a Protime done monthly
- B. Eat more fruits and vegetables
- C. Drink more liquids
- D. Avoid crowds
Correct Answer: A
Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the pleural space, reducing the risk of pneumothorax.
The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is given annually in:
- A. November
- B. December
- C. January
- D. February
Correct Answer: A
Rationale: Influenza vaccines are typically administered in November, before the peak flu season, to ensure immunity during winter months.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.