Nokea
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
- A. Vitamin C, 2,000 mg daily.
- B. Strict bedrest.
- C. Humidification of the air.
- D. Decongestant therapy.
Correct Answer: A
Rationale: Vitamin C (A) is an alternative therapy for colds, with unproven efficacy. Bedrest (B), humidification (C), and decongestants (D) are standard supportive measures.
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Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:
- A. Apply cool compresses to affected extremity
- B. Measure leg circumference
- C. Massage affected extremity
- D. Elevate affected extremity above heart level
- E. Encourage frequent ambulation
- F. Monitor the patient's INR level
- G. Monitor the patient's aPTT level
Correct Answer: B,D,G
Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.
The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
- A. Streptomycin
- B. Para-aminosalicylic (PAS) acid
- C. Isoniazid (INH)
- D. Ethambutol (Myambutol)
Correct Answer: C
Rationale: Isoniazid is the drug of choice for tuberculosis prophylaxis due to its effectiveness in preventing active disease.
Which position is best for the client to be in while the nurse prepares to assess breath sounds?
- A. Sitting
- B. Standing
- C. Lying on the back
- D. Lying on the side
Correct Answer: A
Rationale: Sitting upright allows optimal lung expansion, making it easier to assess breath sounds accurately in a client with asthma.
The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include?
- A. Refer the client to the American Lung Association.
- B. Notify the physical therapy department to arrange for activity training.
- C. Arrange for oxygen therapy to be used at home.
- D. Discuss advance directives with the client.
Correct Answer: C
Rationale: Bronchiolitis obliterans causes irreversible airway obstruction, often requiring home oxygen therapy (C) to manage hypoxemia, a priority for discharge planning. Referrals (A), physical therapy (B), and advance directives (D) are important but secondary to ensuring oxygenation.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.