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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The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.
- A. Dry the feet vigorously with a towel after bathing
- B. Use an over-the-counter kit to treat corns and calluses
- C. Use cotton or lamb’s wool to separate overlapping toes
- D. Wash the feet with lukewarm water
- E. Wear hard-sole shoes and do not go barefoot
Correct Answer: C,D,E
Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.
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 caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s
- A. anterior fontanel
- B. bilateral hearing
- C. pulse pressure
- D. Babinski reflex
Correct Answer: A
Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.
A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: A-C are associated side effects of Tegretol.
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
- A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
- B. Place one AED pad on the chest and the other on the back
- C. Place one AED pad on the upper right chest and the other on the lower left side
- D. Place one AED pad on the upper right chest and dispose of the other
Correct Answer: B
Rationale: For a 2-year-old, adult AED pads can be used by placing one on the chest and one on the back to accommodate smaller anatomy. Continuing CPR without AED delays defibrillation, and other options are incorrect pad placements.