Nokea
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
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An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
A disoriented male client reveals that the client has a self-care deficit (feeding).
Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?
- A. Client explains the relationship between weight loss and change in mental status.
- B. Client identifies the basic four food groups.
- C. Client states he needs to drink more water.
- D. Client feeds self when the nurse stays with him and cues him.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) would not be realistic in a client who is disoriented (2) would not be realistic in a client who is disoriented (3) would not be realistic in a client who is disoriented (4) correct-disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
The school nurse is teaching a group of preschool mothers about poison prevention in the home.
- A. Which statement by a mother indicates that further teaching is necessary?
- B. I should have a bottle of Ipecac for each of my children.'
- C. I should induce vomiting if my child swallows lighter fluid.'
- D. Giving my child water or milk may help dilute the poison.'
- E. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. The other statements are correct: Ipecac is recommended for emergency use, diluting with water or milk can help, and proper storage is essential for prevention.