Nokea
The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?
- A. Rales auscultated in breath sounds
- B. Restlessness
- C. Cyanotic ear lobes
- D. Inspiratory stridor
Correct Answer: C
Rationale: Cyanotic ear lobes indicate severe hypoxemia, a late sign of airway obstruction. Restlessness and stridor are earlier, and rales are unrelated.
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A child with a history of seizures begins to seize suddenly in his hospital room. The nurse would do all of the following interventions EXCEPT
- A. loosen the child's clothing and remove the pillow from his bed.
- B. administer lorazepam rectally.
- C. roll the child on his side.
- D. restrain the child's arms and legs.
Correct Answer: D
Rationale: Restraining during a seizure risks injury. Loosening clothing, removing pillows, rolling to the side, and administering lorazepam (if ordered) are appropriate to ensure safety and stop the seizure.
A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.
A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
- A. I have been helping my family deal with their feelings about the surgery.
- B. I have been having difficulty coping with the surgery and cry frequently.
- C. I have been unable to leave the house or talk to my friends about the surgery.
- D. I am doing just great since the surgery and have gone back to work at my job.
Correct Answer: B
Rationale: normal reaction one month later
The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse?
- A. call again and apologize to the client for the wait
- B. stand behind the bed at the client's head, and pull her up gently from her armpits
- C. since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides
- D. if the client is able to roll and bend her knees, lower the head of the bed and place it in Trendelenburg's position while helping the client bend her knees and push up
Correct Answer: C
Rationale: Using the draw sheet to pull the client up is the safest option to prevent injury to both the client and nurse when assistance is unavailable.
The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication?
- A. I will take the medication each morning after breakfast.
- B. I will check my heart rate before taking the medication.
- C. I will report visual disturbances to my doctor.
- D. I will stop the medication if I develop gastric upset.
Correct Answer: C
Rationale: Reporting visual disturbances is important, as they may indicate levothyroxine overdose or other complications, reflecting proper understanding.