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The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased
- A. Use of accessory muscles
- B. Blood pressure
- C. Level of anxiety
- D. Heart rate
Correct Answer: A
Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (B), anxiety (C), or heart rate (D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.
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A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
- A. Promote the client's comfort
- B. Reduce the drying time
- C. Decrease irritation to the skin
- D. Improve venous return
Correct Answer: D
Rationale: Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.
The nurse is caring for a client with suspected colorectal cancer. Which of the following findings would support a diagnosis of colorectal cancer? Select all that apply.
- A. Fatigue
- B. Blood in the stool
- C. Change in bowel habits
- D. Unintentional weight loss
- E. Elevated hemoglobin level
Correct Answer: A,B,C,D
Rationale: Colorectal cancer often presents with fatigue (A) due to anemia or systemic effects, blood in the stool (B) from tumor bleeding, changes in bowel habits (C) like diarrhea or constipation, and unintentional weight loss (D) from malignancy-related cachexia. Elevated hemoglobin (E) is unlikely, as anemia is more common due to chronic blood loss.
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
- A. Administer the medication as prescribed.
- B. Administer diphenhydramine before administering cefazolin.
- C. Notify the pharmacy that the medication is not appropriate for the client.
- D. Ask the client for more information about the allergic reaction to amoxicillin.
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.