Nokea
The nurse is planning the care of a client diagnosed with asthma and has written a problem of 'anxiety.' Which nursing intervention should be implemented?
- A. Remain with the client.
- B. Notify the health-care provider.
- C. Administer an anxiolytic medication.
- D. Encourage the client to drink fluids.
Correct Answer: A
Rationale: Remaining with the client (A) reduces anxiety through presence and reassurance. Notification (B), anxiolytics (C), and fluids (D) are secondary or unrelated.
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Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
When a previously negative client has a positive reaction to a tuberculin skin test, which information about follow-up is most correct?
- A. A skin test will be performed every 6 months.
- B. A routine chest X-ray is required every year.
- C. The client will need to live alone temporarily.
- D. Antituberculosis drugs will be prescribed.
Correct Answer: D
Rationale: A positive tuberculin test requires further evaluation (e.g., chest X-ray), and antituberculosis drugs may be prescribed for latent or active infection.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
The best evidence that the client understands the procedure for a pulmonary function test is when stating that it involves which action?
- A. Having an X-ray taken
- B. Drawing a blood specimen
- C. Breathing into a mouthpiece
- D. Examining expectorated sputum
Correct Answer: C
Rationale: Pulmonary function tests involve breathing into a mouthpiece to measure lung capacity and airflow.
Which clinical manifestation indicates to the nurse the child has cystic fibrosis?
- A. Wheezing with a productive cough.
- B. Excessive salty sweat secretions.
- C. Multiple vitamin deficiencies.
- D. Clubbing of all fingers.
Correct Answer: B
Rationale: Excessive salty sweat (B) is a hallmark of cystic fibrosis due to defective chloride transport, detectable via sweat chloride testing. Wheezing/cough (A) is non-specific. Vitamin deficiencies (C) and clubbing (D) occur later but are not diagnostic.