Nokea
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving salmeterol (Serevent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler twice a day.
- B. I have a dry mouth.
- C. I feel shaky sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Shakiness suggests systemic beta-agonist effects, a concerning side effect of salmeterol in COPD, requiring evaluation to prevent tachycardia or arrhythmias. Options A, B, and D are less concerning: twice-daily use is standard, dry mouth is common, and rinsing is appropriate.
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A 60-year-old man with a diagnosis of pneumonia.
The nurse should place the patient in a room with which of the following patients?
- A. A 20-year-old in traction for multiple fractures of the left lower leg.
- B. A 35-year-old with recurrent fever of unknown origin.
- C. A 50-year-old recovering alcoholic with cellulitis of the right foot.
- D. An 89-year-old with Alzheimer's disease awaiting nursing home placement.
Correct Answer: C
Rationale: Strategy: Determine the transmission of organisms. (1) patient with fractures are considered 'clean,' don't place with an infectious patient (2) don't know the cause of the fever (3) correct-generalized nonfollicular infection that involves deeper connective tissue, both patients have infections (4) elderly are high risk for developing pneumonia
An adult has received an injection of immunoglobulin. The client asks what this injection will do for him. The nurse's reply includes the information that he will develop which type of immunity as a result of this injection?
- A. Active natural immunity
- B. Active artificial immunity
- C. Passive natural immunity
- D. Passive artificial immunity
Correct Answer: D
Rationale: Immunoglobulin provides preformed antibodies, conferring passive artificial immunity. Active immunity requires the body to produce antibodies, and natural immunity involves natural exposure.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing.
- B. Determine whether she needs a tympanoplasty.
- C. Document that the infection has completely cleared.
- D. Obtain a new prescription in case the infection recurs.
Correct Answer: C
Rationale: A recheck confirms the otitis media has cleared, preventing complications. Hearing tests or tympanoplasty are not routine, and new prescriptions are unnecessary unless recurrence occurs.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.