Nokea
The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues
You may also like to solve these questions
The nurse is caring for a client with a history of hypothyroidism.
- A. Which symptom is expected in a client with untreated hypothyroidism?
- B. Weight loss and irritability.
- C. Cold intolerance and fatigue.
- D. Tachycardia and heat intolerance.
- E. Diarrhea and restlessness.
Correct Answer: B
Rationale: Cold intolerance and fatigue are classic symptoms of hypothyroidism due to slowed metabolism. Weight loss, tachycardia, and diarrhea are associated with hyperthyroidism.
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he felt something give. The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient
- A. with the head of the bed elevated 30°.
- B. with the foot of the bed tilted and the head of the bed down.
- C. with the head of the bed elevated 15°.
- D. with the head of the bed elevated 90°.
Correct Answer: C
Rationale: low Fowler's, reduces stress on suture line, may be placed supine with hips and knees bent
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with food.
- B. I should check my pulse before taking this medication.
- C. I should report dizziness to my doctor.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping carvedilol when feeling better is incorrect, as heart failure requires lifelong treatment to manage symptoms and prevent progression. Options A, B, and C are correct: food reduces GI upset, pulse monitoring detects bradycardia, and dizziness may indicate hypotension.
The nurse teaches a group of boy scouts how to prevent Lyme disease. Which of the following statements, if made by one of the boy scouts to the nurse, would indicate that further teaching is necessary?
- A. When I go on a long hike, I should check any exposed skin for insects every four hours.
- B. When I hike in the woods, I should wear long pants, socks, and a long-sleeved shirt.
- C. I should remove any ticks by crushing them firmly against the skin.
- D. I should reapply insect repellant every couple of hours when hiking.
Correct Answer: C
Rationale: should not be crushed, remove tick with tweezers or fingers and flush down toilet; burning a tick could spread infection