Nokea
The nurse is caring for a client with a history of asthma who is experiencing an acute exacerbation. Which of the following medications should the nurse administer FIRST?
- A. Albuterol nebulizer.
- B. Prednisone PO.
- C. Montelukast PO.
- D. Ipratropium inhaler.
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm and improve airflow. Options B, C, and D are secondary: prednisone reduces inflammation, montelukast prevents attacks, and ipratropium is an adjunct.
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The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
- A. I'm going to try feeding my baby some rice cereal.'
- B. When he wakes at night for a bottle, I feed him.'
- C. I dip his pacifier in honey so he'll take it.'
- D. I keep formula in the refrigerator for 24 hours.'
Correct Answer: C
Rationale: I dip his pacifier in honey so he'll take it.' Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
A school-aged child who was diagnosed two weeks ago with hepatitis A.
Which of the following responses by the nurse is BEST?
- A. You must isolate your child at home for two more weeks.
- B. Why don't you speak with the physician about this matter?
- C. Your child may return to school this week.
- D. Your child may return to school in 2 weeks but cannot participate in sports.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) communicable for 2-3 weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct-type A hepatitis is not infectious within a week or so after the onset of jaundice, child can return to school (4) can return to school, activity at that time depends on the child's energy level
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic.
Which of the following nursing goals should be a priority at this time?
- A. Encourage client to talk about the possibility of dying.
- B. Provide pain assessment and effective pain management.
- C. Manage nutrition and hydration.
- D. Verify that the physician has discussed the prognosis with the family.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct-comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important, but will be difficult if client's pain is not adequately controlled (4) not highest priority
A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made.
It would be MOST important for the nurse to take which of the following actions?
- A. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
- B. Prepare the patient for an immediate cesarean section.
- C. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
- D. Monitor the patient's length and duration of contractions.
Correct Answer: B
Rationale: Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct-implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed