Nokea
The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.
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A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, 'I refuse both radiation and chemotherapy because they are 'hot.' The next action for the nurse to take is to
- A. document the situation in the notes
- B. report the situation to the health care provider
- C. explain the client to the child's disease
- D. ask the client to talk about concerns regarding 'hot' treatments
Correct Answer: D
Rationale: ask the client to talk about concerns regarding 'hot' treatments. The 'hot-cold' system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
- A. Acceptance of the pregnancy
- B. Acceptance of the termination of the pregnancy
- C. Acceptance of the fetus as a separate and unique being
- D. Satisfactory resolution of fears related to giving birth
Correct Answer: A
Rationale: Acceptance of the pregnancy. During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.
A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.
A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
- A. Give acetaminophen or ibuprofen every 6-8 hours to control fever.
- B. Give the infant frequent tepid sponge baths to control the fever.
- C. If the infant develops another seizure, wait 15 minutes to see if it subsides.
- D. Place ice bags under the arms and around the neck to control fever.
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.