Nokea
The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.
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An adult postoperative client vomits, and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- A. Cover the exposed coils of intestine with sterile moist towels or dressings
- B. Pack the intestines back into the abdominal cavity
- C. Irrigate the exposed coils of intestines with sterile water
- D. Take the client's vital signs
Correct Answer: A
Rationale: Covering exposed intestines with sterile moist dressings prevents infection and drying of tissue, stabilizing the client until surgical intervention. Packing intestines risks contamination, irrigation is inappropriate, and vital signs are secondary to immediate protection.
The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first?
- A. Call the health care provider
- B. Determine the client's peak expiratory flow
- C. Notify the client's parents
- D. Remind the client about avoiding triggers
Correct Answer: B
Rationale: Measuring peak expiratory flow assesses asthma severity first. Calling the provider , notifying parents , or discussing triggers follows based on the assessment.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .
A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.
- A. Collecting a urine specimen for culture and sensitivity
- B. Frequent turning and repositioning of the client
- C. Measuring and documenting urine output
- D. Monitoring the color and characteristics of urine output
- E. Teaching the client to strain urine while voiding
Correct Answer: B,C
Rationale: Turning and measuring output are within UAP scope. Collecting specimens , monitoring characteristics , and teaching require nursing judgment.
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.
- A. No sexual activity for at least 6 weeks postoperatively
- B. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site
- C. Refrain from lifting objects weighing >5 lb (2.25 kg) until approved by the HCP
- D. Take a shower daily without soaking chest and leg incisions
- E. Use lotion on incision sites when changing dressing if the areas are dry
Correct Answer: B,C,D
Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.