Nokea
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
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The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any eye pain.
- C. Use the drops every 4 hours.
- D. Avoid regular eye exams.
Correct Answer: B
Rationale: Eye pain may indicate a complication with latanoprost, requiring reporting. Options A, C, and D are incorrect.
The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is
- A. Recurring crises
- B. Continuing drug use
- C. Rationalizing comments
- D. Missing appointments
Correct Answer: B
Rationale: Continuing drug use. Persistent substance use indicates lack of commitment to recovery and ongoing addiction.
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
- A. Explain to him that no one is poisoning his food
- B. Tell him that the food is prepared in the hospital under secure conditions
- C. Taste his food to assure him that it is not being poisoned
- D. Offer him food that is in individual containers
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.