Nokea
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is difficulty breathing relieved by an upright position.
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Which of the following statement best describe implementation in nursing process?
- A. Identifying problems
- B. Setting goals
- C. Carrying out interventions
- D. Evaluating outcomes
Correct Answer: C
Rationale: Implementation is carrying out interventions (C), per nursing process e.g., giving meds. Not identifying (A), setting (B), evaluating (D) action-focused. C best defines implementation's execution, making it correct.
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice enhances iron absorption in iron-deficiency anemia via vitamin C, reducing ferric to ferrous form for better uptake a proven dietary aid. Milk inhibits it, water or apple juice lack this boost. Nurses teach this pairing, improving hemoglobin levels, optimizing therapy for fatigue and pallor relief.
Mr. Gary drinks alcohol to forget his stress. This is an example of?
- A. Adaptive coping
- B. Maladaptive coping
- C. Health promotion
- D. Wellness
Correct Answer: B
Rationale: Drinking to forget stress is maladaptive coping (B) ineffective, harmful, per Lazarus (e.g., addiction risk). Adaptive (A) helps, health promotion (C) enhances, wellness (D) state not coping type. B fits short-term escape, making it correct.
The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
- A. Call a code.
- B. Administer a bronchodilator.
- C. Contact the health care provider.
- D. Disconnect the suction source from the catheter.
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.
The physician has ordered a low-potassium diet for a client with renal failure. Which food should be limited due to its potassium content?
- A. Broccoli
- B. Bananas
- C. Lean beef
- D. White rice
Correct Answer: B
Rationale: Bananas, with ~400-450 mg potassium per fruit, must be limited on a low-potassium diet in renal failure, as impaired kidneys can't excrete excess, risking hyperkalemia broccoli's moderate, beef and rice's low potassium fit better. Nurses teach this, preventing cardiac issues, tailoring diets for renal safety.