Nokea
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.
You may also like to solve these questions
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
- A. 2 hours before the administration of the next I.V. dose.
- B. 3 hours before the administration of the next I.V. dose.
- C. 4 hours before the administration of the next I.V. dose.
- D. Just before the administration of the next I.V. dose.
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
A client with a diagnosis of hyperthyroidism is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Methimazole can cause agranulocytosis, requiring monitoring of white blood cell counts.
The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?
- A. Urinary output
- B. Blood glucose levels
- C. Total bilirubin levels
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly?
- A. Vertigo.
- B. Tinnitus.
- C. Muscle stiffness.
- D. Ataxia.
Correct Answer: B
Rationale: Tinnitus is a sign of ototoxicity, a serious adverse effect of vancomycin that requires prompt reporting to prevent permanent hearing damage.
The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
- A. Sitting with the arms over the head.
- B. Sims' position.
- C. Prone position without a pillow.
- D. Sitting forward with the arms supported on the bedside table.
Correct Answer: D
Rationale: Sitting forward with arms supported allows optimal access to the pleural space and ensures client comfort during thoracentesis.