Nokea
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply.
- A. Assess the client's level of consciousness.
- B. Monitor urine output every shift.
- C. Turn the client every two (2) hours.
- D. Maintain intravenous fluids as ordered.
- E. Place the client in the Fowler's position.
Correct Answer: A,C,D,E
Rationale: LOC assessment (A), turning (C), IV fluids (D), and Fowler’s position (E) support ARDS care. Urine output (B) should be monitored hourly, not per shift.
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The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
- A. Assess respiratory rate and depth.
- B. Provide for adequate rest period.
- C. Administer oxygen as prescribed.
- D. Teach slow abdominal breathing.
Correct Answer: C
Rationale: Administering oxygen as prescribed (C) is the priority for bacterial pneumonia to address hypoxemia, a common issue due to impaired gas exchange. Assessing respiratory rate (A) is important but secondary to ensuring oxygenation. Rest (B) and breathing techniques (D) support recovery but are not the first priority.
An adult is to have a tracheostomy performed. What is the nursing priority?
- A. Shave the neck
- B. Establish a means of communication
- C. Insert a Foley catheter
- D. Start an IV
Correct Answer: B
Rationale: Establishing a means of communication is the priority, as the client will lose the ability to speak post-tracheostomy.
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
- A. The client has an intake of 1,500 mL IV and an output of 1,000 mL.
- B. The client has 450 mL of bright-red drainage in the chest tube.
- C. The client is complaining of pain at a '10' on a 1-to-10 scale.
- D. The client has absent lung sounds on the side of the surgery.
Correct Answer: B
Rationale: 450 mL bright-red drainage (B) suggests hemorrhage, requiring immediate action. Fluid balance (A), severe pain (C), and absent lung sounds (D) are expected or less urgent.
A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed?
- A. Macrolide
- B. Cephalosporins
- C. Pencillin G
- D. Tamiflu
Correct Answer: A
Rationale: For gram-positive bacterial pneumonia in a penicillin-allergic patient, macrolides like azithromycin are commonly prescribed due to their efficacy and safety. Cephalosporins may cross-react with penicillin allergies, Penicillin G is contraindicated, and Tamiflu is for viral infections.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.