Nokea
The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
- A. instruct the client to breathe into a paper bag
- B. place the client in a high Fowler's position
- C. assist the client with pursed lip breathing
- D. administer oxygen at 6L/minute via nasal cannula
Correct Answer: C
Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
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Which of these statements best describes the characteristic of an effective reward-feedback system?
- A. Specific feedback is given as close to the event as possible
- B. Staff are given feedback in equal amounts over time
- C. Positive statements precede a negative statement
- D. Performance goals should be higher than what is attainable
Correct Answer: A
Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
The nurse is caring for a client with panic disorder who is reporting palpitations and intense feelings of fear. The client is shaking and hyperventilating. Which of the following actions would be a priority for the nurse to take?
- A. Assess the client for auditory and visual hallucinations.
- B. Administer a benzodiazepine to the client.
- C. Explore possible triggers for the episode with the client
- D. Remain in the room with the client.
Correct Answer: D
Rationale: Staying with the client (D) provides safety and reassurance, reducing fear and hyperventilation during a panic attack. Hallucinations (A) are not typical, medication (B) is secondary, and exploring triggers (C) is appropriate after stabilization.
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
The nurse is teaching the client regarding bladder retraining. The ability to remain continent depends on the:
- A. Sympathetic nervous system
- B. Parasympathetic nervous system
- C. Central nervous system
- D. Lower motor neurons
Correct Answer: C
Rationale: The central nervous system coordinates bladder control, integrating sensory input and voluntary control for continence. Other systems play secondary roles.