Nokea
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
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If a client with psoriasis is to begin NB-UVB phototherapy, how long should the initial treatment be?
- A. 30 seconds to 1 minute
- B. 1 to 2 minutes
- C. 5 to 10 minutes
- D. 15 to 20 minutes
Correct Answer: A
Rationale: Initial NB-UVB phototherapy starts with 30 seconds to 1 minute (A) to assess skin tolerance and prevent burns. Longer durations (B, C, D) are used in subsequent sessions.
The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?
- A. Administer an analgesic as ordered.
- B. Notify the physician.
- C. Apply a cold pack to the surgical site.
- D. Assess the surgical site for signs of infection.
Correct Answer: D
Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain
A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?
- A. elevated magnesium
- B. lowered magnesium
- C. elevated glucose
- D. lowered glucose
Correct Answer: C
Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.
A client with AIDS has impaired nutrition because of diarrhea. Which diet selection by the client would indicate a need for further teaching of foods that can worsen the diarrhea?
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw vegetables in a tossed salad can exacerbate diarrhea in AIDS patients. Baked chicken, broiled fish, and steamed rice are easier to digest and less likely to worsen diarrhea.
A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, 'I don't believe the doctor; I think he has me confused with another patient.' This is an example of which of Kubler-Ross' stages of dying?
- A. Denial
- B. Anger
- C. Depression
- D. Bargaining
Correct Answer: A
Rationale: The client's statement reflects denial, a stage where patients refuse to accept a terminal diagnosis, per Kubler-Ross' model.