Nokea
The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions?
- A. I will call 911 if my medications don't control an attack.
- B. I will wash my bedding in warm water.
- C. I can still eat at the Chinese restaurant when I want.
- D. If I get a headache, I should take a nonsteroidal anti-inflammatory drug.
Correct Answer: A
Rationale: Calling 911 for uncontrolled asthma (A) shows understanding of emergency action. Warm water (B) is insufficient (hot water needed), Chinese food (C) may contain MSG, and NSAIDs (D) can trigger asthma.
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What nursing action is most appropriate when administering both types of oral medication to this client?
- A. Administer the cough syrup first, then the tablets.
- B. Wait 15 minutes after giving the cough syrup before giving the tablets.
- C. Give the cough syrup between administering the tablets.
- D. Administer the tablets first, then the cough syrup.
Correct Answer: D
Rationale: Administering tablets first ensures they are swallowed properly, followed by the cough syrup, which may coat the throat and aid swallowing.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
- A. A 55-year-old male with hyperlipidemia and diabetes.
- B. A 70-year-old female with severe sepsis.
- C. A 25-year-old male who uses intravenous drugs.
- D. A 65-year-old female who is post-op day 1 after joint replacement surgery.
Correct Answer: B,C,D
Rationale: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.
Which nursing rationale best explains the reason for using a cuffed tracheostomy tube on the client?
- A. The cuff prevents skin breakdown.
- B. The cuff prevents aspiration.
- C. The cuff is more comfortable.
- D. The cuff reduces infection.
Correct Answer: B
Rationale: The cuff on a tracheostomy tube seals the airway, preventing aspiration of secretions or food into the lungs.
Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.