Nokea
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority?
- A. Ineffective breathing pattern.
- B. Knowledge deficit.
- C. Anaphylaxis.
- D. Ineffective coping.
Correct Answer: A
Rationale: Ineffective breathing pattern is a priority in allergic rhinitis due to potential airway obstruction. Knowledge, anaphylaxis risk, and coping are secondary.
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The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
- A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale.
- B. The client diagnosed with SLE who has a rash across the bridge of the nose.
- C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
- D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
Correct Answer: C
Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.
The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first?
- A. Draw a serum for CD4 and complete blood count STAT.
- B. Administer oxygen to the client via nasal cannula.
- C. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB.
- D. Obtain a sputum specimen for culture and sensitivity.
Correct Answer: B
Rationale: Oxygen administration addresses immediate hypoxia in PCP, a priority per ABCs. Labs, antibiotics, and sputum collection are secondary.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis?
- A. Explain the care of a percutaneous endoscopic gastrostomy tube.
- B. Discuss the need to take corticosteroids every day.
- C. Instruct to wear long-sleeved shirts when exposed to sunlight.
- D. Teach the importance of strict hand washing.
Correct Answer: B
Rationale: Corticosteroids are mainstay treatment for polymyositis, reducing muscle inflammation. PEG tubes, sun protection, and handwashing are less relevant.
The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching?
- A. This medication may cause drowsiness so I need to be careful.
- B. I should not drink any type of alcohol or take any antihistamines.
- C. I will increase the fiber in my diet and increase fluid intake.
- D. I stopped taking the medication because I can't afford it.
Correct Answer: D
Rationale: Stopping baclofen due to cost risks symptom worsening, indicating a need for teaching on adherence. Drowsiness, alcohol avoidance, and fiber/fluid intake are correct.