Nokea
The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?
- A. Clear breath sounds
- B. Systolic heart murmur
- C. Temperature of 98.8°F
- D. Negative blood cultures
Correct Answer: B
Rationale: A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection.
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Which of the following is a risk factor for toxic shock syndrome (TSS)?
- A. Changing tampons every 3 hours.
- B. Avoiding use of deodorized tampons.
- C. Alternating tampons with sanitary pads.
- D. Using only tampons at night.
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. The nurse should administer which of the following as prescribed?
- A. Oxygen at 2 L/min via nasal cannula.
- B. Albuterol via nebulizer.
- C. Furosemide intravenously.
- D. Morphine for respiratory distress.
Correct Answer: A, B
Rationale: Low-flow oxygen (2 L/min) and albuterol relieve hypoxemia and bronchospasm in COPD exacerbation.
A client with schizophrenia is prescribed risperidone. Which side effect should the nurse monitor for?
- A. Weight loss.
- B. Extrapyramidal symptoms.
- C. Hypotension.
- D. Increased appetite.
Correct Answer: B
Rationale: Risperidone can cause extrapyramidal symptoms, such as tremors or rigidity, due to dopamine receptor blockade.
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do?
- A. Wait until just before the test to tell the child what will be done.
- B. Ask the child to draw a picture of the body structures involved.
- C. Show the child the equipment that will be used in the test.
- D. Verbally explain what will be done during the test.
Correct Answer: D
Rationale: A verbal explanation in age-appropriate terms helps a 9-year-old understand the procedure, reducing anxiety and promoting cooperation.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed budesonide (Pulmicort). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using budesonide prevents oral candidiasis, a common side effect of inhaled corticosteroids.