Nokea
The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective?
- A. Episodes of spasmodic coughing have decreased
- B. No wheezes are audible on chest auscultation
- C. Oxygen saturation has increased from 88% to 93%
- D. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min
Correct Answer: B
Rationale: Absence of wheezes indicates open airways, the primary goal of asthma treatment. Reduced coughing and improved oxygen saturation are positive but less specific than clear lungs.
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A 79-year-old client asks the nurse if she needs any shots. She reports having had 'all the usual shots when I was younger.' Which immunization is most important for this person to receive?
- A. DPT
- B. MMR
- C. Pneumovax
- D. HiB
Correct Answer: C
Rationale: Pneumovax is critical for adults over 65 to prevent pneumococcal pneumonia, a significant risk in the elderly.
The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action?
- A. Administers the medication in small amounts at the back of the cheek using a syringe
- B. Allows the client to sip the medication from a cup
- C. Expels the medication from a dropper onto the back of the tongue
- D. Mixes the medication in the infant’s bottle of formula
Correct Answer: A
Rationale: Administering small amounts at the back of the cheek with a syringe ensures safe delivery and reduces choking risk in a 2-month-old. Cups, tongue administration, and mixing with formula are unsafe or ineffective.
An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?
- A. Have the client sign the operative permit immediately before the medications take effect
- B. Have the client's next of kin sign the permission form
- C. Ask the client if he/she is willing to undergo surgery, sign the form for the client, and indicate the nurse's name as witness to the client's verbal consent
- D. Report it to the physician so the surgery can be delayed until the client can legally sign a consent form
Correct Answer: D
Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?
- A. Birth weight
- B. Racial differences
- C. Fetal distress in labor
- D. Birth trauma
Correct Answer: C
Rationale: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.