Nokea
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
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A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
Which of the following nursing interventions will be most effective when caring for a client who is experiencing powerlessness?
- A. Make certain that all staff members focus only on the client's capabilities.
- B. Encourage family members to become more responsible for the client's care.
- C. Request a referral to a psychologist.
- D. Include the client in decision making whenever possible.
Correct Answer: D
Rationale: Including the client in decision-making empowers them, reducing feelings of powerlessness by restoring a sense of control.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. The nurse should first:
- A. Administer bronchodilators as ordered.
- B. Initiate oxygen therapy as ordered.
- C. Start I.V. fluids as ordered.
- D. Teach the client diaphragmatic breathing.
Correct Answer: B
Rationale: In an acute asthma attack with severe dyspnea, initiating oxygen therapy corrects hypoxemia, a priority. Bronchodilators are critical but secondary to oxygenation. I.V. fluids and breathing techniques are supportive but not immediate priorities.
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
- A. Maintain circulation
- B. Prevent infection
- C. Relieve pain
- D. Provide education
Correct Answer: A
Rationale: The primary goal post-bypass surgery for PVD is to maintain circulation, ensuring graft patency and adequate blood flow to the extremity to prevent ischemia or graft failure. Infection prevention, pain relief, and education are important but secondary to circulation.