Nokea
The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority?
- A. Wound infection.
- B. Hemorrhage.
- C. Respiratory distress.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Respiratory distress (C) is life-threatening post-laryngectomy, a priority. Infection (A), hemorrhage (B), and knowledge deficit (D) are secondary.
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Which information should the nurse teach the client diagnosed with acute sinusitis?
- A. Instruct the client to complete all the ordered antibiotics.
- B. Teach the client how to irrigate the nasal passages.
- C. Have the client demonstrate how to blow the nose.
- D. Give the client samples of a narcotic analgesic for the headache.
Correct Answer: A
Rationale: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.
If the client develops a severe allergic reaction, which drug should the nurse have available?
- A. Codeine sulfate
- B. Morphine sulfate (Roxanol)
- C. Dopamine (Intropin)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Epinephrine is the first-line treatment for severe allergic reactions (anaphylaxis) as it reverses airway constriction and stabilizes blood pressure.
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
You are providing care to a patient with COPD who is receiving medical treatment for exacerbation. The patient has a history of diabetes, hypertension, and hyperlipidemia. The patient is experiencing extreme hyperglycemia and bruising. Which medication ordered for this patient can cause hyperglycemia and bruising?
- A. Prednisone
- B. Atrovent
- C. Flagyl
- D. Levaquin
Correct Answer: A
Rationale: Prednisone , a corticosteroid, commonly causes hyperglycemia and easy bruising as side effects. Atrovent , Flagyl , and Levaquin are not typically associated with these effects.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.